Comprehensive Practice Exam 1

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

"Assume a reclining or flat position."

A client asks the nurse why vitamin C intake is so important during pregnancy. How should the nurse respond?

"Vitamin C is required to promote blood clot and collagen formation."

A nurse reviews the care plan for an adolescent receiving chemotherapy for leukemia. The adolescent's platelet count is 50,000 μl. The client also has pneumonia. Which item in the care plan should the nurse revise?

Administer oxygen at a rate of 4 L/minute using a non-humidified nasal cannula.

A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?

Monitor vital signs and oxygen saturation every 15 to 30 minutes.

Which recommendation would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps?

Straighten the knees and flex the toes toward the chin.

A 1-year-old child is scheduled for surgery to correct hypospadias and chordee. The nurse explains to the parents that this is the preferred time for surgical repair based on which factor?

The child is too young to have developed castration anxiety.

Which intervention takes priority when admitting an infant with acute gastroenteritis?

obtaining a history of the illness

A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do?

Take acetaminophen or ibuprofen.

The use of a patient-controlled analgesia (PCA) pump is effective in which situation?

The client achieves a therapeutic level of analgesia.

A client with major depression is taking tranylcypromine sulfate, a monoamine oxidase (MAO) inhibitor. The nurse understands that additional teaching is needed when the client reports eating which food?

aged cheese

A client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply.

high-fiber, low-calorie diet use of stool softeners thyroid hormone replacements

Which approach is most appropriate to use with a client diagnosed with a narcissistic personality disorder when discrepancies exist between what the client states and what actually exists?

supportive confrontation

The client has various sensory impairments associated with type 1 diabetes. The nurse determines that the client needs further instruction when the client makes which statement?

"I will avoid kitchen activities."

Which statement indicates that the client with hepatitis B has understood the nurse's discharge teaching?

"I won't drink alcohol for at least 1 year."

When performing discharge teaching with the parents of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, which parent statement about the child's prognosis indicates teaching has been successful?

"My child has a good chance of being potty trained."

A nurse is teaching a client how to use their EpiPen autoinjector. What client statement indicates the teaching is understood? Select all that apply.

-"The EpiPen autoinjector needs to be pointed downward." -"The needle needs to be at a 90-degree angle." -"After I administer the injection, I will massage the area for 10 seconds."

Good dental care is an important measure in reducing the risk of endocarditis. What information about dental care should the nurse include in the teaching plan for a client with mitral stenosis? Select all that apply.

-Brush teeth at least twice a day. -Floss the teeth at least once a day. -Have regular dental checkups.

A nurse is explaining self-catheterization to a female client who has been diagnosed with neurogenic bladder. Which instructions would the nurse include in the home teaching? Select all that apply.

-The meatus would be cleaned with a towelette or soapy washcloth and then rinsed. -Sterile technique is not required.

Following the admission assessment of a neonate born at 42 weeks of gestation, the nurse documents which findings as normal? Select all that apply.

-a three-vessel umbilical cord -peeling skin on the feet -absence of vernix caseosa -cyanosis of the hands and feet

A nurse is assigned to assist with the admission of a laboring client. Which of the following actions are appropriate? Select all that apply.

-asking about the estimated date of childbirth -taking maternal and fetal vital signs -asking about the amount of time between contractions

A client has been admitted with acute abdominal pain in the midepigastric region. The diagnosis of "rule out acute pancreatitis" is made. What assessments would the nurse conduct for this client? Select all that apply.

-back pain and tenderness -nausea and vomiting

A nurse monitors a client, with a tumor of the esophagus, for signs of superior vena cava (SVC) syndrome. For which symptoms would the nurse assess this client? Select all that apply.

-epistaxis -periorbital edema -edema in the hands -dyspnea -mental status changes

A client is diagnosed with gout. Which foods should the nurse instruct the client to eat? Select all that apply.

-green, leafy vegetables -strawberries -eggs

The nurse is assessing a child with Cushing's syndrome. Which findings should the nurse anticipate? Select all that apply.

-obesity -moon-shaped face -emotional instability

Which nursing considerations should the nurse be monitoring when administering chlorothiazide to a client with hypertension? Select all that apply.

-postural hypotension -hypomagnesemia -tachycardia

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort?

Acute pain

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse?

Ask the client to state name and birthdate.

A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?

Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.

An older adult who lives alone is admitted to the hospital for debility and weakness. What is the most important intervention to ensuring cost-effective care is provided for this client?

Ensure case management is actively involved in the client's care to facilitate care coordination.

An older adult had a myocardial infarction (MI) 4 days ago. At 0930, the client's blood pressure is 102/64 mm Hg. After reviewing the client's progress notes (see chart), what should the nurse do first?

Notify the health care provider (HCP).

The client with acute lymphocytic leukemia (ALL) is at risk for infection. What action should the nurse take?

Place the client in a private room.

The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client?

Plan and implement care in a way that is sensitive to the needs of the client.

Assessment of a primigravida in active labor reveals cervical dilation at 9 cm with complete effacement and the fetus at +1 station. What should the nurse do when the primary care provider prescribes meperidine 50 mg intramuscular (IM) for the client?

Refuse to administer the medication to the client.

While doing the shift assessment on a 5-year-old boy, a nurse notices several bruises on his back and arms. The bruises are different colors and sizes. When she asks the child how he got them, he states, "I fell off of my bike." What should the nurse do next?

Talk with the child's parents when they arrive.

The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate?

The neonate will remain on nothing-by-mouth (NPO) status until after surgery.

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?

The severity of discomfort isn't related to the size of varicosities.

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a night-light in the bathroom.

Which condition may contribute to hyperparathyroidism?

chronic renal failure

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

"I make sure my oxygen mask is on tightly so it won't fall off while I nap."

The nurse is assigned to care for an 8-month-old infant with respiratory syncytial virus. The healthcare provider orders palivizumab daily. Which is the nurse's priority action?

Call the healthcare provider.

A nurse is caring for a client with terminal liver cancer. The client states, "I want to control when and how I die." Which choice is the nurse's best action?

Determine whether the client has spoken to the family.

At the completion of a shift, the nurse is participating in the nursing handoff during the transition from the day shift to the evening shift. At the time of shift change, there are not enough evening nurses to meet mandated nurse-client ratios. What is the nurse's best action?

Document the situation, and remain on the unit until sufficient staffing levels are achieved.

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber.

A tour bus has overturned on an exit ramp. Many passengers are injured, but there are no fatalities. The injured passengers will be transported to an emergency center. The nurse at the emergency center who will receive the passengers should plan to respond to which situation in addition to treating injuries?

Passengers may be experiencing feelings of victimization.

Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance?

Promote a bedtime routine such as a warm bath, back rubs, and snacks.

A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral feedings. What should the nurse include in the teaching plan for the parent about oral feedings?

They are best planned in conjunction with observations of the infant's behavioral cues.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for

atelectasis.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device

Which foods are contraindicated for a client taking tranylcypromine?

chicken livers, Chianti wine, and beer

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage?

clear, watery, yellow-tinged drainage

What is the most common cause of medication errors among noninstitutionalized elderly clients?

deficient knowledge

A parent describes that she is trying to get her toddler to eat well but meal times with have become increasingly frustrating. Which behavior would the nurse suggest that the parent modify to make meals a more pleasant experience?

offering several healthy choices

The nurse is assessing the pain level of a postoperative client. The client reports "mild" incisional pain rated at a 4 on the numeric pain scale of 0/10. Which medication should the nurse administer to the client?

oxycodone

A client in the emergency department is diagnosed with benzodiazepine overdose and is lethargic and confused. What would the nurse anticipate as an initial treatment for the overdose?

perform a whole bowel irrigation

A client takes a hormonal contraceptive to prevent pregnancy. The nurse should instruct her to use an alternative contraceptive method when receiving which drug concomitantly?

primidone

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition?

prolapsed cord

A client is admitted with pneumonia and shingles with draining lesions over the right anterior and posterior chest wall. Of the nurses scheduled for the shift, which nurses may be assigned to care for this client? Select all that apply.

-43-year-old female who had a preexposure varicella vaccination -48-year-old male who had shingles one year prior -24-year-old female who has never had the pneumococcal vaccine

The nurse is admitting a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What actions will the nurse perform with planning and providing the client's care? Select all that apply.

-Assign the client to a private room. -Keep dedicated equipment in the client's room.

The nurse is developing a plan of care for a client with allergic rhinitis. What nursing interventions should be included in the plan of care? Select all that apply.

-Assist the client to modify their environment. -Keep appointments for desensitization procedures. -Encourage the client to verbalize feelings about living with a chronic disorder.

A client with chronic obstructive pulmonary disease (COPD) has a signed living will with a do not resuscitate (DNR) request. While the wife was visiting the client, he had a cardiac arrest. The wife requested the client be resuscitated immediately. When the nurse hesitated to start resuscitation procedures, the wife threatened to sue the hospital. What should the nurse do? Select all that apply.

-Carry out the written DNR request and client wishes. -Calmly remind the wife of the client's wishes and DNR request. -Notify the nurse manager of the situation. -Call the chaplain to come and remain with the wife. -Notify the health care provider (HCP).

A nurse is developing short-term goals for a client. Which goals are appropriate short-term goals? Select all that apply.

-Client will ambulate 10 feet twice a day. -Client will use spirometer every 2 hours while awake.

An adult has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply.

-Collect specimens for lab examination. -Assess vital signs. -Initiate support for the respiratory system. -Monitor fluid and electrolyte status. -Provide anti-emetics, as prescribed.

The nurse is caring for a client during the fourth stage of labor. Which complications is the nurse most alert for at this time. Select all that apply.

-Hemorrhage. -Dizziness. -Urinary retention.

A client has been admitted with a left tibial fracture and extensive soft-tissue injuries, and there is a concern for the development of disseminated intravascular clotting (DIC). Which interventions by the nurse are priorities for this client? Select all that apply.

-Improve tissue oxygenation, replace fluids, and correct electrolyte imbalances. -Assess for any signs of bleeding in the gums and other mucous membranes.

Safety concerns lead to the hospitalization of a client with a history of childhood sexual assault and dissociative identity disorder. Which nursing interventions are most important? Select all that apply.

-Initiate precautions for suicide and self-mutilation. -Support using a notebook to continue communications with alters. -Provide anxiety management and rest. -Allow time for processing feelings in a journal.

The nurse is planning care for a client with a Cantor tube. Which nursing measures should be included in the care plan? Select all that apply.

-Inject 10 mL of air into the tube to facilitate drainage. -Apply a water-soluble lubricant to the client's nares. -Coil extra tubing on the client's bed. -Provide mouth care as needed.

Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply.

-Isolate all the suspected clients in the emergency department in one area. -Call housekeeping for diluted household bleach. -Restrict visitors from the emergency department.

The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.

-Level of consciousness. -Motor strength. -Vital signs. -Decreased urine output.

To ensure safe postoperative care of a client after a total hip arthroplasty, which actions are most appropriate for the nurse to perform? Select all that apply.

-Limit movements resulting in internal rotation and adduction of the affected hip. -Teach the client not to cross the legs.

What should the nurse include in the teaching plan for a client with allergies to help control symptoms? Select all that apply.

-Remove dusty items from the environment. -Wear a dampened mask if dust or mold is a problem. -Avoid smoke-filled rooms.

The nurse is reviewing the physician orders for a client who has returned to the unit following a surgical procedure. Which orders should the nurse question? Select all that apply.

-Resume all pre-op orders when the patient returns to the unit. -Offer the client a laxative of choice if there is no bowel movement tomorrow. -Administer medications as taken at home. -Leave medications at bedside for the client to take as needed.

A client is experiencing a blood transfusion reaction. Place the interventions that the nurse should perform in the correct order. All options must be used.

-Stop the transfusion. -Assess for back pain and chills. -Notify the primary provider of client reaction. -Notify blood bank of suspected transfusion reaction. -Send the blood container and tubing to the blood bank. -Document the reaction.

A nurse is discussing end of life care with a client's family in a skilled nursing facility. The client's advanced directive states the client wants no life support treatments. What are important nursing considerations to determine the efficacy of the advanced directive? Select all that apply.

-The client signed the form. -The advanced directive has two signatures. -The advanced directive has a durable power of attorney.

The nurse is caring for a client in labor. Which assessment findings would prompt the nurse to notify the healthcare provider? Select all that apply.

-The client's membranes rupture and the amniotic fluid is green. -Late decelerations are noted on the external fetal monitor strip.

The advanced practice nurse suggests to the client that practicing some yoga positions would address the balance issues that the client mentioned during an appointment. The client makes an appointment with the Women's Health Source Service at the local hospital to see about joining the yoga class. Which information should the nurse include in introducing yoga to this client? Select all that apply.

-This gentle exercise improves a person's flexibility. -People remark that their endurance level improves. -Sometimes people feel their concentration increases. -People report this workout results in better coordination.

The nurse is to wear personal protective equipment (PPE) to administer a chemotherapeutic agent to the client. What guidelines should the nurse use for PPE use and care? Select all that apply.

-Understand the proper use and limitations of PPE. -Use care in removing all items to reduce contamination. -Discard the PPE in containers for contaminated waste.

The nurse is caring for a client on a patient-controlled analgesia (PCA) pump. What additional interventions by the nurse would be effective for pain relief? Select all that apply.

-gentle massage of the area with positioning -encouraging relaxing of inflamed muscles and performing distraction exercises

An older adult client who identifies as a devout Catholic has recently relocated to an assisted-living facility. The client is pleased with most aspects of the new living situation, but laments the fact that the church is no longer close by, which prevents the client from attending mass each morning. What action should the nurse take in response to this information?

Ask the client what it is the client misses most about attending daily mass.

A client who is taking warfarin develops gastrointestinal bleeding. What is the nurse's priority action?

Assess the international normalized ratio (INR) level.

The client has a strong urge to void 6 hours following a transurethral resection for benign prostatic hyperplasia. What are the priority nursing interventions? Select all that apply.

-Assess patency of indwelling catheter. -Open the irrigation system to flush the catheter.

A client was admitted to the emergency department (ED) following a workplace accident and has just experienced brainstem death. The nurse recognizes that the client is likely an appropriate donor for tissue and organs. What actions related to organ donation should the (ED) nurse perform?

-Ensure that the family has a quiet, private place to discuss their decision around tissue donation. -Support and validate the decision that the client's family makes.

A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first-aid for this victim include? Select all that apply.

-Establish an airway with the jaw-thrust maneuver. -Immobilize the spine.

The nurse is caring for a client admitted with severe blood pressure 80/40 hypotension and positive blood cultures for Escherichia coli. What are the priority interventions for this client? Select all that apply.

-Maintain intravenous fluids and vasopressors. -Administer ceftriaxone.

The parent of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which instructions would be most appropriate for the nurse to include when responding to the parent?

Assess the child for constipation.

A client reports to the emergency department after experiencing pain in the left arm. The client reports that they extended their arms in an attempt to prevent a fall. Which fracture type does the nurse anticipate?

Colles' fracture

To reduce the risk of dumping syndrome, what should the nurse teach the client to do?

Decrease the carbohydrate content of meals.

A public health nurse is working in a community immunization clinic. Client information gathered at the clinic is stored and transported to the health unit on a portable memory device. Which action must the nurse take to protect the confidentiality of the information?

Ensure that the information on the memory device is protected.

Before discharge, what should a nurse instruct a client with Addison's disease to do when exposed to periods of stress?

administer hydrocortisone I.M.

The nurse notes that a client taking antipsychotic medications becomes agitated, fearful, and panicky when the client's neck twists to one side and the eyes forcefully draw upward toward the ceiling. Which medication should be administered to the client?

benztropine

The nurse is assessing a client who has a chronic obstructive respiratory disorder. Which finding should be immediately reported to the healthcare provider?

pedal edema

A client experiences initial indications of dizziness after having an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client for which symptoms?

tinnitus

A family member expresses that a client who is aphasic after a cerebral vascular accident (CVA) has not been incontinent at home and questions why a urinary catheter has been inserted without consent. The nurse would recognize this treatment best aligns with which standard of care?

treatment that does not need special consent

The nursing staff has safely and successfully secluded and restrained a client with acute mania who threatened the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?

"You've been restrained until you can manage your behavior."

A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP?

"Your behavior in this situation is considered verbal abuse."

The nurse is teaching a client with a peptic ulcer about the diet that should be followed after discharge. What types of food should the nurse suggest the client include in the diet?

any foods that are tolerated

When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who has severe abdominal pain, the nurse should expect to include which measure in the child's plan of care?

application of an ice bag

When teaching the client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which symptoms to the health care provider (HCP)? Select all that apply.

blood in the urine rash fever above 100° F (37.8° C)

The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which order for intravenous fluids should the nurse should question?

dextrose 5% in water (D5W)

A nurse identifies a client's responses to actual or potential health conditions during which step of the nursing process?

diagnosis

The nurse obtains a pulse rate of 116 beats/min (bpm) before administering digoxin to a client with heart failure who has been receiving digoxin for 2 weeks. The nurse should:

evaluate the client's cardiac rhythm.

The nurse is examining an older adult woman with possible rheumatoid arthritis. The nurse should ask the client if she is having which symptom?

fatigue

The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make?

hearing loss

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

hypokalemia

An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods. The nurse determines the child's biggest nutritional risk is which factor?

impaired oral motor control

A client is experiencing status asthmaticus. For which would the nurse anticipate an immediate order?

inhaled Beta-2 adrenergic agonist

When preparing a 20-month-old for removal of a foreign body in the nasal passage by the health care provider, the nurse should use which method of restraint?

papoose board

Which nursing intervention is most appropriate for a client with multiple myeloma?

preventing bone injury

The nurse covers the myelomeningocele of a neonate with a sterile dressing. Which statements direct the nurse's action?

preventing infection

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

trigeminal neuralgia

When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching and there is a rise in the client's temperature. The nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction with a blood transfusion?

type II (cytolytic, cytotoxic) hypersensitivity reaction

A nurse is caring for a client with terminal liver cancer. The client states, "I want to control when and how I die. I want you to help me." Based on this information, the nurse determines that the client has requested

voluntary euthanasia.

During a client-teaching session, which instruction should a nurse give to a client receiving kaolin and pectin for treatment of diarrhea?

"Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily."

The nurse caring for a postpartum client recalls which of the following are appropriate instructions for the prevention of a urinary tract infection (UTI)? Select all that apply.

-"Drink at least eight 8-ounce glasses of water daily" -"Set your phone alarm to remind you to change your peri-pad every one to two hours" -"Remember to empty her bladder completely every 2-4 hours"

After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply.

-"I will avoid eating meat for 1 to 3 days before getting a stool sample." -"I will take the sample from different areas of the stool that I have passed."

A nurse is providing discharge instructions to the caregivers of a neonate regarding safety. What information will the nurse include in the discharge instructions? Select all that apply.

-"Place the baby monitor in your room when you are sleeping at night." -"Never leave your neonate alone in the tub." -"Verify that your babysitter knows cardiopulmonary resuscitation." -"The car seat should be a rear-facing model." -"Dress the neonate in one more layer than what you are wearing to prevent loss of body heat."

A nursing is caring for a client with a history of multiple sclerosis (MS). The client asks the nurse why so many medications are prescribed. Which statements best explain why many medications are used in the treatment of MS? Select all that apply.

-"The medications manage acute exacerbations." -"The medications modify the disease." -"The medications are used to assist with symptom management."

A primiparous client at 10 weeks' gestation questions the nurse about the need for an ultrasound. She states, "I feel fine, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply.

-"The test helps us view the gross anatomy of the fetus." -"We need to determine gestational age."

The community health nurse is completing a health history of an older adult. Which statement made by the client indicates an increased risk for skin breakdown? Select all that apply.

-"The wound on my foot is taking a long time to heal." -"I have diabetes, which is hard for me to control." -"I use a walker because I had a stroke a few years ago."

A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply.

-"Use pressure-reduction devices." -"Reposition every 1 to 2 hours." -"Teach the family how to care for the wound." -"Clean the area around the ulcer with mild soap."

The client's daughter tells the nurse, "I don't understand the doctor's explanation of my parent's transient global amnesia." What are appropriate responses by the nurse? Select all that apply.

-"Your parent will draw a blank when asked about things that happened a day, a month, or a year ago." -"Transient global amnesia is usually harmless, and a recurrence is unlikely." -"A stroke caused your parent's transient global amnesia and sudden, temporary memory loss." -"Even though there is memory loss, your parent remembers you and recognizes familiar people.'

A family member of a client with schizoid personality disorder asks the nurse, "Why doesn't my brother want any contact with his family?" Which responses are accurate? Select all that apply.

-A person often struggles with their emotions and can become emotional detached. -Your brother doesn't obtain pleasure from social encounters.

A client who is 16 days postpartum calls the nurse on a postpartum unit crying. The client describes her nipples as being cracked and bleeding. The client also says her left breast is sore to touch, and an area under the breast is firm, painful, and red. She is scheduled to go to a nurse-led postpartum breastfeeding support group later that evening. How should the nurse respond to the client's descriptions of her symptoms? Select all that apply.

-Advise her to see her physician as soon as possible. -Advise her to continue to breastfeed. -Advise her to seek the advice of a lactation consultant to prevent future breastfeeding issues.

A client diagnosed with paranoid personality disorder is being admitted on an involuntary 24-hour hold after a physical altercation with a police officer who was investigating the client's threatening phone calls to his neighbors. He states that his neighbors are spying on him for the government, saying, "I want them to stop and leave me alone. Now they have you nurses and doctors involved in their conspiracy." Which nursing approaches are most appropriate? Select all that apply.

-Approach the client in a professional, matter-of-fact manner. -Avoid intrusive interactions with the client. -Develop trust consistently with the client. -Avoid pressuring the client to attend any groups.

The nurse is caring for a postpartum client who states, "I feel so lightheaded when I stand up." Which immediate action(s) should the nurse take? Select all that apply.

-Ask the client to sit or lie down with legs elevated, and reassess the client's symptoms. -Compare the client's most recent hemoglobin laboratory results to baseline. -Instruct the client to use the call light when needing to void and to wait for assistance.

A nurse is working with a schizophrenic client who suddenly begins experiencing auditory hallucinations. Which interactions are appropriate at this time? Select all that apply.

-Ask the client, "What are you experiencing right now?" -Encourage the client to relate the history of the hallucinations. -Tell the client, "I'd like to spend time with you to discuss your hallucinations. Is that okay with you?" -Ask the client if they have recently taken any drugs or alcohol.

A client is admitted to the hospital with Cushing's syndrome. Which nursing interventions are appropriate for this client? Select all that apply.

-Assess for peripheral edema. -Measure intake and output. -Weigh the client daily.

A client is admitted to the hospital with a suspected pulmonary embolus. What actions will the nurse include with client care? Select all that apply.

-Assess temperature every 4 hours. -Monitor client pain levels. -Monitor pulse oximetry every 4 hours. -Monitor the client for blood-tinged sputum.

The nurse is assessing a client with pneumonia in an acute care facility. The nurse notes that the previous intravenous antibiotic has not infused. What are the next actions to ensure safe care? Select all that apply.

-Complete an incident report. -Consult the pharmacist about the missed dose. -Notify the healthcare provider of the missed dose.

A nurse is transferring a client to the operating room for a right leg amputation. What National Patient Safety goals will the operating room nurse follow? Select all that apply.

-Conduct a time out prior to the surgery. -Have the right leg marked as the surgical site. -Read the client's identification arm band.

The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What actions should the nurse take? Select all that apply.

-Confirm the client's vital signs and complete a quick assessment. -Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. -Place the client in the semi-Fowler's position. -Stay with and reassure the client. -Call the health care provider (HCP) and report the situation using SBAR format.

A nurse administering medications is unfamiliar with ropinirole, the medication ordered for a client with Parkinson's disease. What actions should the nurse perform prior to administering the medication? Select all that apply.

-Contact the pharmacist for information about this medication. -Refer to a reliable nursing drug handbook to verify the action, usual dosage, adverse effects, and nursing considerations for this medication.

The nurse administers the wrong dose of a medication. Instead of giving furosemide 20 mg orally, the nurse forgets to break the tablet in half and gives furosemide 40 mg orally. The client experienced no harm as a result. What should the nurse do? Select all that apply.

-Continue to monitor the client's vital signs and urinary output. -Notify the health care provider, supervisor, client, and family. -Complete an incident report, outlining the events of the incident.

The nurse is caring for a child with elevated serum potassium. When teaching the parents about dietary restrictions related to this condition, which of the following would be appropriate information? Select all that apply.

-Do not drink orange juice. -Asparagus should be avoided.

A client with osteoarthritis will undergo an arthrocentesis on a painful, edematous knee. What directives should be included in the nursing plan of care? Select all that apply.

-Explain the procedure. -Assess the site for bleeding. -Offer pain medication.

A neonatal nurse is assessing a 2-week-old's pain level following open heart surgery. Which scales would be appropriate to assess the pain level using an age appropriate scale? Select all that apply.

-FLACC scale -NIPS scale

A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which interventions are indicated? Select all that apply.

-Have the parent read to the child. -Encourage the parent to hold the child.

An adolescent scored a 20 on the Depression Scale for Children indicating moderate depression. Citalopram 20 mg daily is prescribed. Which nursing instructions are essential? Select all that apply.

-Improvement in mood may take up to 1 month. -Monitor the adolescent for signs of self-harm. -Have the parent be involved in medication management. -Discard any MAO inhibitor medications in home.

The nurse working the mother-baby unit teaches the client about the facility's measures to prevent infant abduction. What precautions does the nurse discuss? Select all that apply.

-Infant footprints and a color photograph are taken soon after birth. -Only let staff wearing an appropriate ID badge transport your baby. -Notify the staff about anyone who appears unusual.

The client has been diagnosed with breast cancer and the oncologist has ordered tamoxifen. Which point(s) are important for the nurse to teach the client? Select all that apply.

-It is important to see the gynecologist regularly. -The medication will cause menopause. -The client should freeze her eggs. -This medication puts the client at risk for cancer in other parts of the body.

The home health nurse is consulting with a family about creating a safe environment in their home for a person who has Alzheimer's disease. What is the most important information for the nurse to provide? Select all that apply.

-Keep all household cleaning products in a locked cabinet. -Supervise the client when cooking or fixing a snack. -Place all matches and cigarette lighters in a safe place. -Install locks on places where garden equipment is kept. -Monitor the use of stoves, ovens, and heating appliances.

The nurse is caring for a 5-year-old child with a skin rash. Which of these instructions should the nurse give to the parent to help prevent skin breakdown? Select all that apply.

-Keep the child's fingernails short. -Provide a coloring book and crayons. -Use prescribed antihistamines as needed. -Apply gloves to the child's hands.

A nurse is demonstrating umbilical cord care to a client who recently gave birth. Which actions should the nurse teach the client to perform? Select all that apply.

-Keep the diaper below the umbilical cord. -Only sponge bathe the neonate until the umbilical cord falls off. -Allow the cord to be exposed to air.

While managing a client's immediate post-cardiac catheterization period, which interventions are priorities? Select all that apply.

-Monitor vital signs every 15 minutes for the first hour. -Restrict the client to bed rest for 2 to 6 hours. -Assess the catheter insertion site every 30 minutes for 4 hours. -Note any limb discoloration and reported numbness. -Assess for any signs of hematoma formation.

A single parent has only one child. The parent shares dreading the fall when the child leaves for college. Which type(s) of loss is this client likely to experience? Select all that apply.

-Perceived loss -Psychological loss -Maturational loss -Anticipatory loss

Which nursing interventions would be appropriate when caring for a client during the first 24 hours after an appendectomy? Select all that apply.

-Place the client in a semi-Fowler's position. -Teach the client how to care for the incision.

The nurse working on a neurological unit is assigned a client with spinal cord injury. Which nursing actions can the nurse delegate to the nursing student on the unit? Select all that apply.

-Provide pin care. -Administer oral medication to decrease muscle spasticity.

The client is in the postanesthesia care unit (PACU) recovering from surgery. The nurse administers the prescribed hydromorphone IV push (IVP). Five minutes later the nurse notes a respiratory rate of 9 breaths per minute on the same client. Which interventions should the nurse implement? Select all that apply.

-Re-assess the client's respiratory rate in 5 minutes. -Administer naloxone.

The nurse is making a home visit to an older adult client who is living with his son's family. The client has scald burns on the hands, both forearms, and on the neck (10% first- and second-degree burns). What should the nurse do? Select all that apply.

-Rinse the wounds with cool water. -Remove clothing near the area. -Call for transport to a hospital. -Investigate the possibility of elder abuse.

The nurse should include which instructions in the teaching plan for a client with chronic sinusitis? Select all that apply.

-Take a hot shower in the morning and evening. -Report a temperature of 102° F (38.9° C) or higher.

An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply.

-The scar will be small. -The teen will be back in school in 1 week.

The nurse is teaching a client with a latex allergy about birth control methods to protect against sexually transmitted diseases. What information should be included in the teaching? Select all that apply.

-Use of latex condoms, cervical caps, and/or diaphragms are contraindicated for men and women with latex allergy. -A natural condom can be placed over a latex condom for protection.

A nurse is obtaining consent for a bone marrow aspiration. Which actions should the nurse take? Select all that apply.

-Witness the client signing the consent form. -Evaluate that the client understands the procedure. -Verify that the client is signing the consent form of his or her own free will. -Determine that the client understands postprocedure care.

The charge nurse is completing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in contact precautions? Select all that apply.

-a client diagnosed with respiratory syncytial virus (RSV) -a client with a new onset of diarrhea -a client with a positive wound culture for methicillin-resistant Staphylococcus aureus (MRSA)

The supper meal tray this evening for clients who have a diet as tolerated consists of a beef patty with gravy, baked potatoe, steamed peas, and a mixed fruit cup for dessert. For which clients may this meal be inappropriate? Select all that apply.

-a client whose religion was listed as "Hindu" on admission -a newly admitted client who is self-declared as a Seventh Day Adventist

A client with hospital-acquired pneumonia (HAP) is told that the intravenous (I.V.) antibiotics will be discontinued and will now taken orally. What information needs to be included when the nurse explains the change to the client and family member? Select all that apply.

-a description of the client's current clinical progress -the rationale for continuing to take the medication orally -the acknowledgment of a healthy gastrointestinal tract

A 10-year-old child is admitted to the hospital with a temperature of 104°F (40°C) and is difficult to arouse. The child has history of Varicella two weeks ago. Reye's syndrome is suspected. Which objective data is supportive of the diagnosis? Select all that apply.

-an abnormal liver biopsy -vomiting -coma -disorientation

The nurse is gathering data on a client with pernicious anemia. Which data would support this diagnosis? Select all that apply.

-angular cheilitis -smooth, bright-red tongue -sensitivity to cold -dyspnea on exertion

A client who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply.

-chromosomal defects -neural tube defects -sex of the fetus

The nurse is caring for several postpartum clients. Which client(s) will the nurse anticipate to be at risk for experiencing strong contractions after birth? Select all that apply.

-client who gave birth to a neonate weighing 12 lb (5.4 kg) -client who is breastfeeding -client who is a multipara

A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment being received for SIADH is effective? Select all that apply.

-decrease in body weight -increase in urine output -decrease in urine osmolarity

The nurse is caring for a client following a cystocele and rectocele repair. The nurse has just received the client from the post anesthesia care unit (PACU). Which healthcare provider orders would the nurse question? Select all that apply.

-discontinue Foley catheter -maintain sitting position

The nurse is reviewing assessment data and admission orders of a client. The provider has ordered the I.V. administration of phenytoin. The nurse determines that further intervention is required when the admission assessment includes which findings? Select all that apply.

-episodic nosebleeds -history of Stokes-Adams syndrome -history of bone marrow depression

A client with Parkinson's disease is receiving carbidopa-levodopa therapy. Which clinical manifestations are common side effects associated with this medication? Select all that apply.

-facial tics -head bobbing -pill rolling

A client is admitted to the psychiatric unit for depression after being arrested for exhibitionism. What are most likely the concerns of the client? Select all that apply.

-facing a criminal record as a sexual offender -possibly losing the client's bus driving job -being embarrassed because people knowing about the crime

The nurse is teaching a woman who is 18 weeks' pregnant about normal findings. Which findings are expected at this time? Select all that apply.

-fundal height of approximately 18 cm -quickening -less urinary frequency

The nurse is designing a benchmarking study to gather information about nursing care practices for wound care. Which sources of information are used for benchmarking? Select all that apply. government reports

-government reports -literature reviews -standard-setting organizations -databases

Fluoxetine has been prescribed for a client with an eating disorders. Which symptoms would alert the nurse to the development of serotonin syndrome? Select all that apply

-hallucinations -fever -anxiety -tremors -diaphoresis

A nurse is evaluating the labs of a client with heart failure. Which lab values are expected findings? Select all that apply.

-hemoglobin 14.2 g/dL, hematocrit (Hct) 32.8% -Serum sodium 130 mEq/L -microalbuminuria and proteinuria

A client arrives to the emergency department (ED), with reports of chest pain. Electrocardiograph (ECG) exhibits an elevated ST segment. What are the priority actions by the nurse? Select all that apply.

-improving myocardial oxygenation -relieving pain -reduce cardiac output

The nurse is conducting a health history on a client with peripheral vascular problems. Which statements would suggest increasing problems with the peripheral vascular circulation? Select all that apply.

-increased pain in the legs at rest and a chronic ulceration on the right heel -Acute lower leg pain and swelling to the left calf over the past 24 hours -more swelling in the feet at the end of the day. -numbness and tingling in both feet when sitting for long periods of time

A child is undergoing testing to rule out a diagnosis of Kawasaki disease. Which test results would support this diagnosis? Select all that apply.

-leukocytosis -elevated C-reactive protein levels

The nurse is caring for a client with bladder cancer with an ileal conduit. What is a characteristic of the urine in the ostomy immediately postoperatively? Select all that apply.

-mucus threads in the urine -urinary output > 30 mL per hour

A child with suspected infective endocarditis arrives at the emergency department. Which assessment findings would the nurse anticipate in this child? Select all that apply.

-murmur -low-grade fever -malaise -headache

The client is prescribed aspirin, a first-generation nonsteroidal anti-inflammatory drug (NSAID). Which conditions would contraindicate the use of aspirin? Select all that apply.

-peptic ulcer disease -hemophilia

A child has been diagnosed with type 1 diabetes mellitus. Which signs and symptoms would the nurse manage with this diagnosis? Select all that apply.

-polyuria -weakness -weight loss -postprandial nausea

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows moderate variability with a baseline of 142 beats per minute (bpm). What interventions should the nurse include in the client's plan of care? Select all that apply.

-providing encouraging labor support -documenting the findings

What dietary recommendations should the nurse provide for a client with intermittent claudication to assist in the prevention of disease? Select all that apply.

-reduce fat -decrease cholesterol

After an explosion at a local factory, a nurse is performing victim triage at the site. The nurse encounters a victim who reports an injury on the ankle. What assessment finding indicates that the nurse should give the victim a yellow tag using the START triage system? Select all that apply.

-respirations 20 breaths/min -capillary refill less than 2 seconds -heart rate 88 beats/min -nonambulatory

A nurse is teaching a client about adequate nutritional intake during pregnancy. The client has recently emigrated to the United States from Haiti. Based on the client's cultural background, what foods would the nurse expect her to eat during pregnancy? Select all that apply.

-rice -plantains -red fruits

The nurse is reviewing a client's medication list and providing instruction on how to take each medication. Which medication should not be taken with grapefruit juice? Select all that apply.

-simvastin -fexofenadine -buspirone -erythromycin

The nurse is preparing to assist the health care provider (HCP) with a cervical check for a client whose membranes have ruptured. What equipment should the nurse have ready for the HCP? Select all that apply.

-sterile gloves -sterile lubricant

A client with a history of varicose veins has just delivered her first baby. A nurse suspects that the mother has developed pulmonary embolus. Which symptoms would confirm this suspicion? Select all that apply.

-sudden dyspnea -diaphoresis -Confusion

Which finding should the nurse report to the client's health care provider for a client with unstable type 1 diabetes mellitus? Select all that apply.

-systolic blood pressure, 145 mm Hg -diastolic blood pressure, 87 mm Hg -high-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L) -glycosylated hemoglobin (HbA1c), 10.2% (0.1) -triglycerides, 425 mg/dL (23.6 mmol/L)

The nurse is a member of a team that is planning a client-centered, community-based approach to care of clients with chronic obstructive pulmonary disease. In which areas should the team focus on improving quality of care and delivery? Select all that apply.

-the community -clinical information systems -delivery system design

The nurse should monitor evidence-based research and incorporate it into clinical practice and client teaching. When teaching a Hispanic client about an infectious skin condition, the nurse should focus on which factors? Select all that apply.

-the level of health care literacy demonstrated by the client -the specific health questions that the client asks the nurse -illness and treatment information specific to the client

The nurse is collaborating with the dietician to plan the diet of a client with a latex allergy. Which foods should not be included in the client's meal plan? Select all that apply.

-tomato soup -grapes -potatoes

A client diagnosed with posttraumatic stress disorder is readmitted for suicidal thoughts and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply.

-trying relaxation techniques to help decrease her anxiety before bedtime -taking the quetiapine 25 mg as needed as prescribed by the health care provider -listening to calming music as she tries to fall asleep -leaving her door slightly open to decrease noise during the nightly checks

The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which information in the report? Select all that apply.

-vehicle's description -current location of parties involved

Following an infection, the client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which symptom? Select all that apply.

-vertigo -nausea -ataxia

The nurse is irrigating a draining wound prior to packing with gauze. Which nursing actions are appropriate? Select all that apply.

-washing the hands immediately after removing the sterile gloves -removing the dressing with nonsterile gloves -donning sterile gloves for the irrigation -wearing a face shield during the irrigation

A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assess the attendee as being unresponsive. Indicate how the nurse would respond by placing the following actions in chronological order. All options must be used

1-Appoint a person to call 911. 2-Perform chest compressions. 3-Perform a head tilt-chin lift maneuver. 4-Check for normal breathing. 5-Deliver two rescue breaths. 6-Check for a pulse.

An adolescent is brought into the emergency department with a compound fracture. He refuses pain medication stating that his parents are drug addicts and he does not want to become an addict. What order should the nurse perform the actions from first to last? All options must be used.

1-Assess the adolescent's pain using a developmentally appropriate pain scale. 2-Notify the health care provider (HCP) that the adolescent is refusing pain medication. 3-Allow the adolescent an opportunity to express his concerns about becoming addicted. 4-Provide the adolescent with educational information on safe use of pain medications.

A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of lorazepam and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. What should the nurse do in order of priority from first to last? All options must be used.

1-Page the ED healthcare provider and prepare to give diazepam intravenously. 2-Monitor the client's safety and place seizure pads on the cart rails. 3-Record the time, duration, and nature of the seizures. 4-Ask the friend about the client's medical history and current medications.

A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea?

Offer yogurt several times a day.

A school nurse has been asked to conduct a sexuality education class for fourth grade children. What is the most effective method for the nurse to use to present the material to the children?

Read sexual education pamphlets with the children.

Which information should the nurse include in a postoperative teaching plan for a client with a laryngectomy?

Reassure the client that normal eating will be possible after healing has occurred.

A nurse working on an inpatient unit is assigned two clients diagnosed with severe depression and suicide attempts. After reviewing the client care assignment, which nursing action should the nurse initiate?

Request a change in the client care assignment.

Which client findings require the nurse's attention first?

a gravida 3, para 2 at 30 weeks' gestation with nausea, vomiting, and epigastric pain

When caring for a client who has recently given birth, the nurse assesses the client for urinary retention with overflow. Which sign or symptom provides the most accurate picture of retention with overflow?

a varying urge to urinate with an average output of 100 ml

Which comment from a client indicates a need for further instruction after being taught about taking ciprofloxacin?

"I must drink 1,000 to 1,500 mL of water a day."

A client at 33 weeks' gestation is leaking amniotic fluid. She is placed on an external fetal monitor. The monitor indicates uterine irritability, and contractions are occurring every 4 to 6 minutes. The provider orders nifedipine 20 mg po now and every 8 hours until birth or contractions cease. What is the most important information for the nurse to teach this client concerning nifedipine?

"You may experience nausea and some dizziness."

A client with lymphoma tells the nurse that a holistic practitioner has offered to treat the client with coffee enemas. How does the nurse respond?

"You should speak with your oncologist about this treatment."

A client with major depression states to the nurse, "My heart is turning to stone." Which reply by the nurse is most therapeutic?

"You sound like you feel frightened."

A nurse has recently had multiple clients who were admitted to the intensive care unit (ICU) without advance directives. The nurse wants to improve the number of clients with advance directives on the unit. Place the steps the nurse would use to implement a performance improvement for advance directives in the correct order. All options must be used.

1-Discussions on advance directives are not being consistently obtained. 2-Decide all nurses will be responsible for helping clients with advance directives. 3-Appoint a small group to monitor the progress at monthly intervals. 4-Evaluate whether the new plan improved the number of advance directives obtained. 5-Plan a new strategy with a smaller group being responsible for advance directives.

A client is to receive a blood transfusion of packed RBCs for severe anemia. Place the following steps in the order a nurse would follow to administer this product. All options must be used. You Selected:

1-Record baseline vital signs. 2-Check the packed cells for abnormal color, clumping, gas bubbles, and expiration date. 3-Verify the blood bag identification, ABO group, and Rh compatibility against the client information. 4-Put on gloves, a gown, and a face shield. 5-Flush the intravenous tubing with normal saline solution. Begin blood administration. 6-Remain with the client and watch for signs of a transfusion reaction.

A home care nurse is preparing for the next day by reviewing his/her home visit assignments. In which order should the nurse visit the clients based on priority interventions? All options must be used.

1-a client injecting insulin for daily blood glucose coverage, day two 2-a client as a new admission requiring a daily morning dose of vancomycin 3-a client requiring a laboratory study for warfarin evening dosing 4-a client receiving a monthly injection of cobalamin 5-a client with a final visit for ostomy teaching

The client underwent a bowel resection and was in the postanesthesia recovery unit for 1 hour. On return from the recovery room, the client reports having pain and asks for medication. In what order (from first to last) should the nurse perform the actions? All options must be used.

1 Establish the location and severity of the pain. 2 Reposition the client to the opposite side. 3 Determine when the client last received pain medication. 4 Administer pain medication as prescribed.

The nurse is discontinuing a peripheral venous access device. Place the steps in the order that the nurse should perform them. All options must be used.

1 Perform hand hygiene. 2 Put on gloves. 3 Remove tape and sterile dressing. 4 Withdraw catheter. 5 Apply pressure to area just above the insertion site. 6 Apply an occlusive dressing to site.

The nurse assesses the fundus of a woman who gave birth to a baby 24 hours ago. Where would the nurse expect the fundus to be located at this time?

1 cm below the umbilicus

Three days after a cholecystectomy, a client states, "I feel like my stomach is going to burst." The client is taking a regular diet. After determining that vital signs are stable, in which order of priority from first to last does the nurse assist the client? All options must be used.

1-Auscultate for bowel sounds. 2-Offer 120 mL of hot liquids. 3-Position the client on right side. 4-Encourage ambulation.

The nurse is preparing to administer one unit of packed red blood cells. Place the steps in order the nurse needs to perform pre-procedure. All options must be used.

1-Confirm that the transfusion has been prescribed. 2-Check that the client's blood has been typed and cross-matched. 3-Verify the client has signed a written consent form. 4-Explain the procedure to the client. 5-Take the client's vital signs. 6-Wash hands, put gloves on, and insert appropriate size needle into the peripheral vein.

A physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 mL. How many milliliters of solution should the nurse administer with each dose? Record your answer using a whole number.

14

A child weighing 23 kg is admitted to the hospital for a surgical procedure. The nurse reviews the standing intravenous fluid prescription (see exhibit). At what hourly rate (mL/hour) should the nurse infuse the maintenance fluid? Record the answer as a whole number.

65

A client who has a urinary diversion tells the nurse, "This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore." What is an appropriate goal for the nurse to set with this client?

Express fears about the urinary diversion.

A nurse discovers that a hospitalized client with stage 4 esophageal cancer and major depression has a gun in the home. What is the best nursing intervention to help the client remain safe after discharge?

Talk with the health care provider (HCP) about requiring gun removal as a condition of discharge.

A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make?

Testicular cancer is a highly curable type of cancer.

The nurse reviews the plan of care of an adolescent client with diabetes using an insulin pump. This is the second visit that the client has come without his parent. The client's hemoglobin A1C and blood glucose levels are normal. The client reports that he is playing a sport and has not had any hypoglycemic episodes. Which factor does the nurse determine is the best indicator that the client is transitioning to independent self-management?

attending health care appointments alone

The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to:

avoid caffeine.

The nurse is placing patches on both eyes of client with detachment of the retina. What is the expected outcome of patching?

reduced rapid eye movements

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?

regular

When a child is able to grasp the idea that a ball continues to exist even though the child's parent placed the ball under a hat, the child is in which stage in the development of logical thinking, according to Piaget?

sensorimotor

A nurse is assessing a client who underwent esophagogastroduodenoscopy (EGD) for postoperative complications. Which sign or symptom would indicate a potential complication of this procedure?

severe abdominal pain

A nurse is assessing a client with hepatitis A. The client reports having a poor appetite and the presence of food causes nausea. What should the nurse encourage the client to eat?

the majority of the calories in the morning during small frequent snacks

Pyrantel pamoate is prescribed for an 8-year-old child with pinworms. The child has an 18-month-old brother and a 4-year-old sister. The nurse should be sure that the parents are also treating which family members with this drug?

the parents and sister

The nurse instructs a group of colleagues on actions to take to prevent back injuries when providing client care. Which statement by a colleague indicates that additional teaching is required?

"A back belt prevents injuries."

A client who has been hospitalized with schizophrenia for 8 years can't perform activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of dressing or grooming self-care deficit related to inability to function without assistance. What is an appropriate goal for this client?

"Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month."

The home health nurse attends to a terminally ill client whose older adult spouse is the primary caregiver. The spouse states, "I am so ashamed to admit that sometimes I wish it would all just end. I am so tired." How should the nurse respond?

"It sounds like you are overwhelmed. How can we better support you through this process?"

A 20-year-old client with paranoid schizophrenia is in the 4th day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which explanation by the nurse is most accurate and therapeutic?

"You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease."

A parent asks the nurse about using a car seat for a toddler who is in a hip spica cast. What should the nurse should tell the parent?

"You will need a specially designed car seat for your toddler."

What information about vision would be most important for the nurse to include in the discharge plan of a client who had cataract removal?

"You'll need to relearn to judge distances accurately."

The student nurse is administering medications to the clients. The nurse educator asks the student, "Which of the medication orders have the potential to cause a medication error?" What is the best response by the student? Select all that apply.

"cc" "QOD" "MgSO4"

A client presents at the health care provider's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? Select all that apply.

-Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. -Severe itching of the affected areas, especially at night, is a common finding. -All of the client's linens and clothing should immediately be washed in hot water.

The nurse in the emergency department is triaging victims of an airplane crash. Prioritize the clients in the order in which they should be treated from first to last. All options must be used.

1-q 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing 2-a 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused 3-a 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes 4-a 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm

During her first prenatal visit, a client expresses concern about gaining weight. What is the nurse's first action?

Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.

The health care provider prescribes 30 mg of methylphenidate to a child with autism. The methylphenidate is to be given in two divided doses. The concentration is 10 mg/5 mL. How many mL of methylphenidate should the nurse give per dose? Record the answer with one decimal place.

7.5

An 8-year-old child with juvenile idiopathic arthritis (JIA) is being admitted to the hospital for evaluation of progressively increasing symptoms. The child weighs 60 lb (27 kg) and is 50 inches (127 cm) tall. The nurse is reconciling the medications the parent brought from home with the medications prescribed. (See chart.) What should the nurse do?

Request a cetirizine prescription from the health care provider (HCP).

The health care provider prescribed intravenous naloxone to reverse the respiratory depression from morphine administration. After administration of the naloxone, what should the nurse do?

Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.

A registered nurse (RN) is receiving an admission to the medical-surgical unit. Which nursing responsibilities would be appropriate to delegate to the licensed practical/vocational nurse (LPN/VN) on the unit? Select all that apply.

Preparing the bed and room for the admission Collecting the IV pole and assessment equipment Assisting a client with incentive spirometry

The nurse has just received the change of shift report on the clients on the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first?

a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia

A client at 36 weeks' gestation, begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for:

abruptio placentae

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed their wish to not be intubated with the client's partner of 5 years, whom the client has designated as healthcare power of attorney. The client's children want their parent to be intubated. A nurse caring for this client knows that

clients commonly confer healthcare power of attorney on someone who shares their personal values and beliefs.

A client is undergoing fertility testing, and it has been determined that she is oligo-ovulatory. Which drug would be used to stimulate ovulation in this type of menstrual cycle?

clomiphene

A client at 6-weeks' gestation comes to the emergency department, and a transvaginal ultrasound confirms ectopic pregnancy with the tube intact. The client will be treated medically. What medication will the nurse prepare to administer to this client?

methotrexate

The health care provider (HCP) has determined that a primigravid client in active labor requires a cesarean birth because of cephalopelvic disproportion. After the birth of a healthy neonate, which assessment should the nurse make first?

nasopharyngeal secretions

The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not develop:

osteoporosis.

A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to:

reassign the client to another nurse who is experienced in blood administration.

A client who suffered a stroke has a nursing diagnosis of ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?

repositioning the client every 2 hours

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolbutamide. Which laboratory test is the most important for confirming this disorder?

serum osmolarity

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. Which additional assessment finding will the nurse assess for?

severe abdominal pain with direct palpation or rebound tenderness

Testicular cancer risk is highest for adolescents and men younger than age 35. To specifically address testicular cancer risk, a nurse should modify client teaching for male clients to include

testicular self-examination.

A three-year-old child brought to the emergency department is not breathing and is cyanotic. The parent states that the child has likely swallowed a penny. What is the nurse's first intervention?

administer abdominal thrusts

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate?

adduction and flexion of the extremities with gently rounded shoulders

A client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that their spouse sleeps in another room because the client's snoring keeps the spouse awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

acromegaly

During the home visit, a breastfeeding client asks the nurse what contraception method she and her partner should use until she has her 6-week postpartal examination. Which method would be most appropriate for the nurse to suggest?

condom with spermicide

A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether the client wants to file a report, the nurse's next priority is to offer which intervention to the client?

crisis intervention

Which nursing measure will likely decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning?

changing the surgical dressings using sterile technique

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

daily doses of isoniazid, 300 mg for 6 months to 1 year

When making ethical decisions about caring for preschoolers, a nurse should remember to

provide beneficial care and avoid harming the child.