Final ATI Questions ( ALL THE TESTS)

A nurse is assessing a school aged child after a ventriculoperitoneal shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

A. Abdominal distention - a VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed

A nurse is developing a plan of care for a client who has GERD. The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss

A. Aspiration

A nurse is caring for a client who has a MI 2 hrs ago and is receiving alteplase. Which of the following findings should the nurse identify as an adverse effect of receiving this medication? A. Bleeding B. Increased clot formation C. SOB D. Blockage of the central venous catheter

A. Bleeding

A nurse is providing teaching to the parent of a child who has CF and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra abdominal pressure

A. Bulky stools - implement interventions to help decrease the bulk of the childs stools

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statments should the nurse include in the teaching? A. Carbos make up 55% B. Proteins make up 70% C. Fats make up 45% D. Fiber make up than 10%

A. Carbos make up 55% - the ideal diet is composed of 55% carbs, 20% proteins, 25% fat, and less than 10% saturated fat

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprungs disease D. Crohns disease

A. Celiac disease

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check vital signs B. Request a dietitian consult C. Suggest that the client rests before eating the meal D. Request an order for an antiemetic

A. Check vital signs - It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm.

A nurse is caring for a client who had a MI 5 days ago. The patient reports a sudden onset of SOB, frothy pink sputum. The nurse expect to hear what breath sounds? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction Rub

A. Coarse crackles - patient who had a recent Mi is at risk for Left sided heart failure

A nurse is admitting a client who is experiencing an exacerbation of HF. At which of the following times should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to discharge

A. During the admission process

A nurse is reviewing labs for a client taking risperidone. The nurse should identify that which of the following results indicates a potential adverse reaction to the medication? A. Elevated blood glucose B. Elevated WBC C. Decreased Platelet count D. Decreased AST

A. Elevated blood glucose - All second generation antipsychotic medications cause diabetes, weight gain, and dyslipidemia

A nurse is teaching a female client with a new diagnosis of Lupus about factors that can trigger an exacerbation of lupus. The nurse should determine that further teaching is needed when patient identifies which of the following as an exacerbation factor? A. Exercise B. Pregnancy C. Infection D. Sunlight

A. Exercise

A nurse is assessing a client who was diagnosed with schizophrenia. Which of the following client findings is considered a positive symptom of schizophrenia? A. Hallucinations B. Social withdrawal C. Anergia D. Flat affect

A. Hallucinations

A nurse is providing teaching to a parent of a child who has asthma and a new RX for a cromolyn sodium MDI. Which of the following statements by the parent indicates the need for further teaching? A. I will give my child a dose as soon as wheezing starts B. My child should rinse out his mouth after using the inhaler C. My child should exhale completely before placing the inhaler in his mouth D. If my child has difficulty breathing in the dose, a spacer can be used

A. I will give my child a dose as soon as wheezing starts

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the childs protein intake B. Decrease the childs calorie intake C. Increase the childs fiber intake D. Decrease the childs salt intake

A. Increase the child's protein intake

A nurse is teaching a client who has iron deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

A. Lentils

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? A. Maintain the integrity of the sac B. Promote maternal - infant bonding C. Educate the parents about the defect D. Provides age-appropriate stimulation

A. Maintain the integrity of the sac - Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.

A nurse is planning care for a suspect failure to thrive 10-month-old. Which of the following interventions should the nurse include in the plan of care? A. Observe the parent's actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during feedings

A. Observe the parent's actions when feeding the child B. Maintain a detailed record of food and fluid intake

A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? A. Oranges and Tomatoes B. Carrots and bananas C. Potatoes and squash D. Whole wheat and beans

A. Oranges and Tomatoes - decrease high acid foods such as alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint

A nurse is caring for an infant who has TOF and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? A. Place the in a knee - chest position B. Initiate a fluid restriction C. Provide oxygen by nasal cannula D. Administer acetaminophen

A. Place the in a knee - chest position - this position reduces the return of desaturated blood from the legs through the venous system and promotes the diversion of blood into the pulmonary artery.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following lab results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 B. Digoxin level .7 C. Hemoglobin 9.8 D. Calcium 8.0

A. Potassium 2.8 - flattened T wave or the developmental of U waves is indicative of a low potassium

A nurse is providing dietary teaching to the parent of a toddler with CF. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

A. Provide a high fat diet for the toddler - children with CF have impaired intestinal absorption of fat

Patient has GERD. The nurse should expect the client to report which of the following manifestations? A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss

A. Regurgitation B. Nausea C. Belching D. Heartburn

A nurse in a MED-SURg unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain - a manifestation of a PE is sudden chest pain that is sharp and stabbing

A nurse on a MED-Surg unit is caring for a client who is postoperative following hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea - PE have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs

A nurse is providing teaching to a client with HF about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the patient B. The emphasis the provider places C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client

A. The involvement of the patient

A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta D. Patent Ductus arteriosus

A. Transposition of the great arteries - An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation.

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fatal hear rate. Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal Head compression C. Fetal ventricular septal defect D. Umbilical cord compression

A. Uteroplacental insufficiency

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1 kg in 1 day B. Pitting edema C. Client reported of a cough D. DNP level of 100

A. Weight gain of 1 kg in 1 day - weight gain indicates that the client is retaining fluid and is at risk of fluid volume overload

a nurse is assessing a 2 month old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

A. Weight gain of 1.8 kg - A 4lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.

A nurse is assessing a 2 month old who has VSD. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8kg B. Heart rate of 125 C. Soft fontanel D. Systemic murmur

A. Weight gain of 1.8kg - indicates increased fluid and worsening of the child's heart failure

A nurse is assessing a 6 month infant who has a cardiax catherization with right femoral entry to diagnose a possible CHD. Which of the following findings should the nurse report to the provider? A. cool toes on the right foot B. Weak pulses on the feet C. Positive babinski D. erythema on the right foot

A. cool toes on the right foot

A nurse is assessing a client who has CF. Which of the following pieces of information indicates a therapeutic response to pancreatic enzyme replacement? A. is having 1 - 2 bowel movements daily B. glucose level is elevated C. experienced weight loss D. abdominal distention

A. is having 1 - 2 bowel movements daily - indicates adequate absorption of food and therapeutic response to pancreatic enzyme replacement

A nurse is caring for a shcool-aged child who has cystic fibrosis and has been using a corticosteroid inhaler for long-term treatment. Which of the following findings should the nurse identify as an adverse effect of long-term use of this medication? A. small stature for age B. decreased weight C. Poor dentition D. Atrophied muscles

A. small stature for age

A nurse is providing teaching to the parents of an infant who has HF and a new RX of digoxin. Which of the following pieces of information should the nurse include? A. withhold the medication if the infant's HR is less than 110 B. Mix the medication with formula C. Expect to vomit D. Double the dose if the patient has edema

A. withhold the medication if the infant's HR is less than 110

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the clients perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infectiosn

B. Addressing the clients perception of the disease process and what might have triggered past attacks

A nurse is reviewing the medication history of a client who has mild intermittent asthma. The nurse should anticipate a RX for which of the following inhalers for the client? A. Ipratropium B. Albuterol Sulfate C. Tiotropium D. Budesonide

B. Albuterol Sulfate

A nurse is planning care for an infant who has HF. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? Select all A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi upright during feedings E. Provide gavage feeding if RR exceeds 80

B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi upright during feedings E. Provide gavage feeding if RR exceeds 80 - infants should feed every 3 hours

A nurse is preparing an older adult who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home? A. Blood glucose B. Blood pressure C. Daily weights D. Sensation in the feet

B. Blood pressure

A nurse is assessing a client who has left sided HF. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. JVD D. Hepatomegaly

B. Crackles in the lung bases

A nurse is assessing an older adult client for signs of dehydration. Which of the following findings is an expected part of the aging process? A. Elevated Urine gravity B. Decreased creatinine clearance C. Dry oral mucous membranes D. Poor skin turgor over the sternum

B. Decreased creatinine clearance - kidneys have a decreased ability to concentrate urine as we age

A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect? A. Nystagmus B. Dilated pupils C. Hypersomnia D. Depress

B. Dilated pupils - Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system.

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart Failure D. Pulmonary edema

B. Dysrhythmias - dysrhythmias are the most common cause of death following MI. Therefore, nurses should monitor clients ECGs carefully for dysrhythmias and report and treat them immediately

A nurse is assessing the respiratory status of a newborn who was born 2 hrs ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. RR of 56 D. Irregular RR

B. Expiratory grunting - indication of respiratory distress that is caused by narrowing of the bronchi

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for CAD? A. Hypothyroidism B. HTN C. Diabetes Mellitus D. Hyperlipidemia E. Tobacco smoking

B. HTN C. Diabetes Mellitus D. Hyperlipidemia E. Tobacco smoking

A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. I will use my peak flow meter whenever I feel SOB B. I will continue to take my medication when my peak flow rate is in the green zone C. I need to use the average of 3 readings when I measure my flow rate D. My asthma is being controlled if my flow rate is in the yellow zone

B. I will continue to take my medication when my peak flow rate is in the green zone

A nurse is monitoring a client who has HF related to mitral stenosis. The client reports SOB on exertion. Which of the following conditions should the nurse expect? A. Increased CO B. Increase Pulmonary congestion C. Decreased left atrial pressure D. Decrease pulmonary artery pressure

B. Increase Pulmonary congestion - Defect in the valve, the l atrial pressure rises and the l atrium dilates. The increased pressure results in a backflow of blood from the l atrium to the pulmonary vein and into the lungs resulting in pulmonary congestion

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome? A. History of asthma B. Large waist size C. Hypotension D. Hypoglycemia

B. Large waist size - Central obesity due to excessive abdominal fat is a risk factor for metabolic syndrome. Metabolic syndrome increases the risk for the development of diabetes and coronary artery disease.

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? A. Encourage deep breaths B. Mobilize secretions in the airways C. Dilate the bronchioles D. Stimulate the cough reflex

B. Mobilize secretions in the airways

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic Murmur B. Murmur at the left sternal border C. Cyanosis that increase with crying D. Widened pulse pressure

B. Murmur at the left sternal border - a hole in the septal wall between the ventricles is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.

A nurse is giving a presentation about preventing DVT. Which of the following should the nurse include as a risk factor for this disorder? A. BMI of 20 B. Oral Contraceptive use C. HTN D. High Calcium intake E. Immobility

B. Oral Contraceptive use E. Immobility

A nurse is caring for an infant who has congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? A. Coarctation of the aorta B. Patent ductus arteriosus C. Tetralogy of Fallot D. Tricuspid atresia

B. Patent ductus arteriosus - With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriosus and back to the pulmonary artery and lungs.

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. Which of the following is an expect finding? A. Family history of Alzheimer's disease B. Personal hx of alcohol use disorder C. Undergoing current treatment for HIV D. Current rehabilitation for opiate addiction

B. Personal hx of alcohol use disorder - Wernicke-Korsakoff syndrome is a type of secondary dementia as a result of thiamine deficiency that is commonly associated with alcohol use disorder. The syndrome results in confusion and memory loss and is treated with thiamine replacement therapy.

A nurse is providing instructions about pursed-lip breathing for a client who has COPD w/ emphysema. This breathing technique accomplishes which of the following? A. Increased oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority? A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Confronting the use of denial and other defense mechanisms D. Educating the client about the consequences of alcohol misuse

B. Providing for adequate hydration and rest - Providing for the client's physical needs should be the nurse's priority. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which fo the following acid - base imbalance? A. Resp. Alkalosis B. Resp. Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

B. Resp. Acidosis - common in COPD because patient is unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following finding should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. NEC

B. Retinopathy

A nurse is teaching a client who has asthma and a RX for a fluticasone dry power inhaler. Which of the following instructions should the nurse include in the teaching? A. This medication should be taken at the start of your symptoms B. Rinse you mouth after administering this medication C. Shake the canister prior to administering this medication D. This medication relaxes your airways to decrease your symptoms

B. Rinse you mouth after administering this medication

A nurse is caring for a client who has CF and has a RX for high dose ibuprofen daily. The nurse should identify that which of the following is an expected outcome for the client receiving this medication? A. Thinned pulmonary secretions that are retained in the airways B. Slowed progressions of pulmonary damage C. potentiated action of bronchodilator therapy D. Decreased risk of fevers associated with CF

B. Slowed progressions of pulmonary damage -given to slow the progression of pulmonary damage by suppressing the inflammatory response that causes pulmonary damage

A nurse is planning care for a client who has COPD, requires continuous oxygen therapy and is being discharged. Which of the following referrals should the nurse recommend? A. Spiritual advisor B. Social Worker C. PT D. OT

B. Social Worker

A nurse is assessing a school age child who has celiac disease. Which of the following findings should the nurse expect? A. Elevated sweat chloride B. Steatorrhea C. Clubbing of the fingers D. Jaundice

B. Steatorrhea

A nurse is assessing a newborn for manifestations of a PDA. Which of the following findings should the nurse expect? A. Cyanosis with crying B. Systolic murmur C. Weak pulses D. Chronic hypoxemia

B. Systolic murmur

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? A. cardiogenic shock B. dysrhythmias C. Heart failure D. Pulmonary edema

B. dysrhythmias - most common cause of death following MI

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse exepect? A. Muscle aches and chills B. Fatigue and depression C. Anxiety and diaphoresis D. Arrhythmia and respiratory depression

C. Anxiety and diaphoresis - Alcohol withdrawal symptoms usually occur within hours of the client's last drink, and symptoms intensify over 1 to 3 days after the last drink. - Early signs of withdrawal include anxiety, diaphoresis, irritability, mood swings, tremors, dilated pupils, tachycardia, hypertension, anorexia and insomnia. Alcohol withdrawal requires medical attention to safely manage the client and avoid death.

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse perform first? A. Apply mechanical restains to the client B. Administer PRN haloperidol IM to the client C. Approach the client in a non-threatening manner D. Place the client in seclusion

C. Approach the client in a non threatening manner least restrictive priority setting framework

A nurse is caring for a client who has a RX for clopidogrel. The nurse should monitor the client for which of the following adverse effects? A. Insomnia B. Hypotension C. Bleeding D. Constipation

C. Bleeding - Remeber clopidogrel is an antiplatelet drug

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia - The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A. Anorexia B. Weight Gain C. Breathlessness D. Distended abdomen

C. Breathlessness - Manifestation of left - sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion

A nurse is caring for a client who has wenicke-korsakoff syndrome due to alcohol use disorder. Which of the following findings should the nurse expect? A. Increased arousal B. Arrhythmias C. Confusion D. Esophageal pain

C. Confusion - a client with this syndrome should exhibit neurological and cognitive manifestations due to thiamine deficiency

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. Chest pain that increases when sitting upright

C. Dyspnea with hiccups

A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis. Which of the following actions should the nurse include in the plan? A. Encourage the child to sleep for 1 Hour each afternoon B. Apply cold compresses to the child's affected joints each morning C. Encourage the child to participate in physical activites D. Limit the child's intake of food that are high in uric acid

C. Encourage the child to participate in physical activites - remain active to promote mobility and joint function

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the clients brain? A. Occipital B. Temporal C. Frontal D. Limbic

C. Frontal

A nurse is caring for a COPD patient and is recieving 2L via nasal. The client is dyspenic and has an oxygen sat of 85%. Which of the following actions should the nurse take? A. Place patient on nonrebreather B. Prepare client for intubation C. Increase oxygen and request an arterial blood gas determination D. Position the client in supine and administer antianxiety

C. Increase oxygen and request an arterial blood gas determination

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal Flaring D. Meconium stools

C. Nasal Flaring

A nurse is caring for a client who reports crushing chest pain. The nurse reviews the client's ECG results and notes ST changes. Which of the following medications should the nurse administer? A. Simvastatin B. Furosemide C. Nitroglyercin D. Slidenafil

C. Nitroglycerin - treats angina

a nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

C. Palpate the abdomen for bladder distension - neurogenic bladder is a common complication of spina bifida

A nurse is discussing risk factors for NEC in newborns. Which of the following risk factors should the nurse include? A. Post term birth B. Macrosomia C. RSD D. Maternal gestational diabetes

C. RSD - can cause intestinal ischemia 2nd to hypoxia

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

C. Tachycardia - Dyspnea, restlessness, HA, and increased BP are indications of impending resp. failure

A nurse is orienting a new nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective? A. Performs range of motion on the infants hips B. Maintains a dry dressing over the sac C. Takes an axillary temperature D. Places the infant in a side-lying position

C. Takes an axillary temperature - Rectal temperatures should be avoided in infants who have spina bifida due to the risk for irritation and rectal prolapse.

A nurse is teaching the parents of an infant who has GER. Which of the following instructions about the feeding therapies should the nurse recommend? A. Apply the infants diaper snugly prior to feeding B. Administer nasogastric feedings C. Thicken feedings with rice cereal D. Place the infant in a later position for 1 hour after feeding

C. Thicken feedings with rice cereal - Thickening the food decreases infants risk of GER and promote weight gain

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias - the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the hearts electrical system.

A nurse is assessing a client who has HF and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? A. Suppression of dysrhythmias B. Increased AV conduction C. Visual disturbances D. Weight gain

C. Visual disturbances - recognize that N, V, abdominal discomfort, fatigue, and vision changes are common manifestations of digoxin toxicity

A nurse is providing teaching to a client with a new DX of HF who has an RX for furosemide. Which of the following statements should the nurse include in the teaching? A. You can take Ibuprofen for HA B. You may see an increase in swelling in the lower extremities C. You should eat foods rich in potassium while on this medication D. You should take this medication at bedtime

C. You should eat foods rich in potassium while on this medication - medication is a diuretic that depletes potassium, sodium, chloride, Mg and water

A nurse is caring for a client who has severe asthma and allergic rhinitis. The client is taking theophylline. Which of the following medications should the nurse identify as being incompatible with theophylline? A. Cromolyn B. Albuterol C. Zafirlukast D. Methylprednisolone

C. Zafirlukast - suppress the metabolism of theophylline which can lead to toxicity

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client? A. raisins B. black tea C. black beans D. whole milk

C. black beans -The nurse should recommend that the client eat dried fruits, such as raisins, to increase iron intake. However, a small box (1.5 oz) of raisins contains only 0.81 mg of iron. That is why black beans are correct

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. 5th intercostal space just medial to the midclavicular line B. 2nd intercostal space to the left of the sternum C. 5th intercostal space to the left of the sternum D. 2nd intercostal space to the right of the sternum

D. 2nd intercostal space to the right of the sternum - the aortic valve is located in the 2nd intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is reviewing the lab data for a client who is recieving clozapine for schizophrenia. The nurse should identify which of the following findings as a potential adverse effect of the this medication? A. Fasting blood glucose 95 B. Triglycerides 135 C. Total cholesterol 175 D. Absolute neutrophil count 1200

D. Absolute neutrophil count 1200 This is less than the range of 2500 - 8000

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent Neural tube defect? A. Take multivitamin daily B. Decrease consumption of mercury C. Increase dairy consumption D. Begin taking a folic acid supplement

D. Begin taking a folic acid supplement

A nurse is caring for a client who is having difficult with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum

D. Cerebellum

A nurse is assessing a client who has R sided HF. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema

D. Dependent edema

A nurse is providing teaching for a client who has a new dx of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. The pain usually lasts longer than 20 min B. The pain often radiates to the jaw or the back C. The pain persists with rest and organic nitrates D. Exertion and anxiety can trigger the pain

D. Exertion and anxiety can trigger the pain - Exertion and anxiety can trigger the pain of angina, unless it is variant angina, which occurs at rest.

A nurse is caring for a child with CF who has a pulmonary infection. Which of the following findings is the nurses' priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions

D. Inability to clear secretions - REMEBER ABCs BITCH

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort

D. Lower back discomfort - AAA involves a widening , stretching or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerves.

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? A. Remove the hood every hour for 10 min to facilitate bonding B. Insert an orogastric tube for decompression of the stomach C. Place the newborn in Trendelenburg position D. Maintain oxygen saturations between 93% and 95%.

D. Maintain oxygen saturations between 93% and 95%. - Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

A nurse assesses a client who has been taking simvastatin to treat hyperlipidemia. Which of the following statements by the client indicates an adverse effect of the medication that should be reported to the provider immediately? A. I have had occasional constipation B. I have had some gas C. My head has been hurting for some days D. My legs feel weak and achy

D. My legs feel weak and achy

A nurse is caring for a client who has COPD and is experiencing SOB. Which of the following actions shouyld the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed lip breathing D. Place the client in an upright position

D. Place the client in an upright position

A nurse is reviewing the morning labs for an infant who is on digoxin and furosemide for the treatment of HF. Which of the following findings should the nurse report to the provider? A. Sodium 140 B. Calcium 10.2 C. Chloride 100 D. Potassium 3.2

D. Potassium 3.2 - below the expected range for an infant

A nurse is caring for a client who is experiencing an acute asthma exacerbation. Which of the following medication should the nurse identify as being contraindications for this client? A. Dextromethorphan B. Montelukast C. Ciprofloxacin D. Propranolol

D. Propranolol

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000 B. WBC 4,000 C. Thyroid stimulating hormone 7.0 D. RBC 6.8 million

D. RBC 6.8 million - a child who has TOF experiences cyanosis; therefore, the body responds by increasing RBC production in an attempt to supply oxygen to all body parts.

A nurse is showing a client who has R sided HF an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the R atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

D. Superior vena cava

A nurse is reviewing the progress notes for a client who has HF. The provider notes some improvement in the clients CO. The nurse should understand that CO reflects which of the following physiologic parameters? A. The % of blood the ventricles pump during each beat B. The amount of blood the L ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

D. The heart rate times the stroke volume

A nurse in an ED is assessing a school aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. sudden decrease in wheezing

D. sudden decrease in wheezing - silent chest indicates ventilatory failure and imminent resp. arrest

A nurse working in a mental health unit is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referrals should the nurse recommend to the provider? A. Occupational therapist B. Social worker C. Physical Therapist D. Spiritual support

B. Social worker

A nurse is caring for a client who has schizophrenia and is hearing voices. Which of the following actions is the nurses priority? A. Ask the client what the voices are saying B. Focus the client's attention on reality based activities C. Make eye contact when speaking with the client D. Encourage the client to listen to music through headphones

A. Ask the client what the voices are saying The greatest risk for this client is an injury to self or others due to command hallucinations

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as Me, see, bee, and tree. The nurse should recognize that the client is demonstrating which of the following positive manifestations of schizophrenia? A. Clang association B. Echolalia C. Magical thinking D. Word salad

A. Clang association

A nurse is assessing a client who has schizophrenia. The client suddenly states, I am blue, so are you, and I am leaving on a choo choo choo A. Clang association B. Word salad C. Neologism D. Echolalia

A. Clang association a pattern of speech that rhyme or contain a string of words that have the same beginning sounds

A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the past 2 months. Which of the following findings demonstrates that the medication has been effective? A. Client reports that hallucinations occur less frequently B. Client sleeps uninterrupted for 6 hr each nigh C. Client reports that she is the "most important person the unit" D. The client demonstrates stereotyped behaviors

A. Client reports that hallucinations occur less frequently

While participating in a community health fair, a nurse is providing information to a client who has a BP of 150/90 during screening. Which of the following actions should the nurse take? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go the nearest ED C. Instruct the client to follow-up with a provider within 6 mnths D. Explain to the client that he is not at risk unless he has manifestations of HTN

A. Give the client a written record of his BP to bring to his provider

A nurse is admitting a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia? A. Anhedonia B. Avolition C. Flat effect D. Hallucinations

D. Hallucinations

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C. Heightened Immune Response D. Bleeding tendencies

A. Hyperglycemia - stress causes an increased secretion of cortisol, which can lead to HTN and Hyperglycemia

A nurse is caring for an older client who had a stroke. After assessing the ABCs , which of the following assessments is the nurse's priority? A. LOC B. Muscle tone C. Sensory CHanges D. Gag Reflex

A. LOC

A nurse in a mental health facility is admitting a client who has antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit? A. Lack of remorse B. Self mutilation C. Delusional behavior D. Splitting

A. Lack of remorse clients who have antisocial personality disorder lack empathy for others and show no remorse or guilt for callous behavior

A nurse is caring for an older adult client who has gout and refuses to eat. The client's provider has authorized the client's family to bring food from home. Which of the following foods should the nurse recommend that the client avoid? A. Lentil soup B. Cheese sandwich C. Yogurt D. Raisins

A. Lentil soup - gout, renal calculi, or both in conjunction need to have diets rich in purines

A client has a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse recommend to the client. (SELECT ALL) A. Nurse B. OT C. Speech therapies D. PT E. Respiratory therapies

A. Nurse B. OT C. Speech therapies D. PT

A nurse is assessing a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? A. Positive B. Cognitive C. Negative D. Affective

A. Positive Positive symptoms are seen early in clients who have schizophrenia and are easier to detect than other types of symptoms.

A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take? A. Present a single idea in a sentence B. Avoid using nonverbal communication techniques C. Speak loudly D. Use simplified language

A. Present a single idea in a sentence - loss of ability to understand or express speech,

A nurse is reviewing the medical record of a client. The medication administration record shows the client is taking clopidogrel. Which of the following events should the nurse expect in the client's medical history? A. Recent myocardial infraction B. HX of hemorrhagic stroke C. Current outbreak of psoriasis D. HX of HTN

A. Recent myocardial infraction - the nurse should expect to indicate a hx of an atherosclerotic event such as a MI, ischemic stroke, or peripheral vascular disease - clopidogrel is a antiplatelet drug

A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? A. Relieve the clients pain B. Encourage the client to increase fluid intake C. monitor the clients I&O D. Strain the clients urine

A. Relieve the clients pain

A nurse is caring for a client who has schizophrenia. The client states, my internal organs have turned to stone. The nurse should document this finding as which of the following types of delusions? A. Somatic B. Reference C. Persecutory D. Grandiose

A. Somatic believe that a body part is no longer functioning in a realistic or expected manner

A nurse is planning care for a female client who has severe IBS and RX for alosetron. Which of the following interventions should the nurse include in the plan of care? A. The client must sign an agreement with the provider before beginning alosetron B. The client must stop taking medication if diarrhea continues for 1 week after beginning C. The client should expect to have a slower heart rate while taking alosetron D. The client should use a barrier birth control method because alosetron interacts with oral contraceptives

A. The client must sign an agreement with the provider before beginning alosetron - medication has a fatal adverse effects associated with constipation and bowel obstruction

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine

A. The clients ability to clear oral secretions - ABCS ALWAYS!!!!!

A nurse is assessing a client who has a new prescription for chlorpromazine to treat schizophrenia. The client has a mask like facial expression and is experiencing involuntary movements and tremor. Which of the following medications should the nurse anticipate administering? A. amantadine B. bupropion C. phenelzine D. hydroxyzine

A. amantadine Patient is experiencing Parkinsonism, which is an adverse effect of the antipsychotic medication chlorpromazine

A nurse is planning recreational activities for a young adult who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse plan for this client? A. walking with a staff member B. playing ping-pong in the dayroom with another client C. Playing basketball with other clients in the gym D. Riding a stationary bike alone in the fitness room

A. walking with a staff member

A nurse is providing teaching to a young adult client who has HX of calcium oxalate renal calculi. Which of the following instructions should the nurse include? A. Drink fruit punch or juice at every meal B. Consume 1000 of calcium daily C. Take 1g of vitamin C daily D. Increase your daily bran intake

B. Consume 1000 of calcium daily

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body

B. Difficulty with speech

A nurse is preparing to administer a feeding via a GT to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the clients bed C. Flush the tube with .9 sodium chloride for irrigation D. Verify that the clients gastric pH is above 4

B. Elevate the head of the clients bed - patients with brain injuries are typically unable to swallow effectively and thus cannot protect their airway from aspiration

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 - 2 hr of delivery? A. Nalaxone B. Erythromycin ophthalmic ointment C. Poractant alfa D. Rotavirus immunizations

B. Erythromycin ophthalmic ointment

A nurse is assessing a client who has schizophrenia. which of the following statements by the client should the nurse recognizes as an erotomaniac delusion? A. My coworker is trying to poison me because he is afraid I will take his job B. I have only met Jenny twice, but I know she loves me C. I am selling my house before the earthquake hits in May D. The foil on my walls prevents the government from controlling me

B. I have only met Jenny twice, but I know she loves me Believes another person desires him or her romantically after meeting only a few time is demonstrating an erotomaniac delusion

A nurse is caring for a term newborn 90 mins after a scheduled c section. The newborns APGAR score was 9. The HR is 120, RR 70. There are no indications of nasal flaring, or grunting, retractions. Which of the following actions should the nurse take? A. Request a RX for CPAP B. Initiate close observations of the newborn for indications of RD C. Consult a respiratory therapist for chest physiotherapy D. Request and order for nitric oxide therapy

B. Initiate close observations of the newborn for indications of RD - The newborn has manifestations of transient tachypnea. This condition is thought to be a result of an incomplete clearance of fluid form the lungs at birth

A nurse is providing teaching to a newly licensed nurse about metoclopramide. The nurse should highlight that which of the following conditions is a contraindication to this medication? A. hyperthyroidism B. Intestinal obstruction C. Glaucoma D. Low blood pressure

B. Intestinal obstruction - Metoclopramide reduces N/V by increasing gastric motility and promoting gastric emptying

A nurse is caring for a client who has schizophrenia and states, " My doctor is trying to kill me. Which of the following responses should the nurse make? A. Why would you say that your doctor is trying to kill you? B. It must be frightening to feel that your doctor is trying to kill you C. Your doctor wants to help you not kill you D. How long has your doctor been trying to kill you

B. It must be frightening to feel that your doctor is trying to kill you

A nurse is caring for a client who has generalized anxiety disorder. Which of the following goals should the nurse include in the discharge plan of care for this client. A. Use whistling or singing as a distraction to control hallucinations B. Make independent decisions about daily events C. Verbalize a realistic perception of personal appearance D. Decrease the use of ritualistic behaviors

B. Make independent decisions about daily events GAD demonstrates indecisiveness and has unrealistic and persistent anxiety most days of the week

A nurse is providing discharge teaching to parents whose infant had a VP shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? A. We will check his abdomen daily for signs of fluid accumulation B. We will notify the doctor right away if he has a fever C. we should keep a helmet on him when he's awake D. We can expect him to have occasional seizure episodes

B. We will notify the doctor right away if he has a fever - infection is a risk after VP shunt placement

A nurse is caring for a client who has schizophrenia. The client states I like to play ball. Walk down the hall. Be careful not to fall. The nurse should identify that the client is using which of the following? A. pressured speech B. circumstantial speech C. Clang association D. Flight of idea

C. Clang association

A nurse is assessing a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicated that the client is physically dependent on the medication? A. exhibits paranioa B. Client reports having insomnia C. Client reports eating excessively D. Client has an increased HR

C. Client reports eating excessively. Amphetamine causes appetite suppression

A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine fumarate. Which of the following blood tests should be performed periodically? A. potassium B. Uric acid C. Glucose D. Calcium

C. Glucose at risk for abnormal glucose metabolism

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms A. I just feel so hopeless B. The government has been watching my house C. I am unable to remember to brush my teeth D. I no longer enjoy the activities I used to love

C. I am unable to remember to brush my teeth S/S impaired concentration, judgement and problem solving

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clan association? A. Her mannerologies are poor B. My dog blank a boat to supreme heights C. I can play the flute while wearing a suit. You are cute D. My joints ache. My friend is in the joint

C. I can play the flute while wearing a suit. You are cute

A nurse is caring for a client who had a stroke and is at risk for falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN RX for restraints

C. Monitor the client at least once every hour - the use of 4 raised side rails on the clients bed is considered a physical restraint that the nurse cannot employ w/out a RX

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first? A. Teach the client strategies to decrease the hallucinations B. Identify whether the client is on antipsychotic medications C. Distract the client from the hallucinations D. Explore what the voices are saying to the client.

D. Explore what the voices are saying to the client.

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt, and he appears to be actively hallucinating. Which of the following should be the nurses priority assessment? A. Perception of reality B. Ability to follow directions C. Physical needs D. Mental status

C. Physical needs Maslow's Hierarchy levels 1. Needs 2. Safety and security 3. love and belonging 4. personal achievement 5. self esteem

A nurse is discussing risk factors for necrotizing enterocolitis in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post term birth B. Macrosomia C. RDS D. Maternal gestational diabetes

C. RDS - RDS is a risk factor for NEC. RD causes intestinal ischemia secondary to hypoxia

A nurse on an acute mental health unit is assessing a client who has OCD. Which of the following behaviors should the nurse expect? A. Being intentionally dishonest B. Jumping rapidly between topics of conversations C. Tapping the 4 sides of a light switch D. Mimicking the movements of another person

C. Tapping the 4 sides of a light switch

A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. The nurse should identify that these manifestations indicate which of the following adverse effects? A. Akathisia B. Acute dystonia C. Tardive Dyskinesia D. Pseudoparkinsonism

C. Tardive Dyskinesia

A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make? A. This medication is a tricyclic antidepressant and will improve your mood B. This medication is an opioid antagonist that blocks the pleasurable effects of alcohol C. This medication is an antipsychotic that controls manifestations of schizophrenia D. This medication is a cholinesterase inhibitor that slows the progression of dementia

C. This medication is an antipsychotic that controls manifestations of schizophrenia medication is thought to act directly on dopamine receptors in the brain to prevent the reuptake of dopamine, thereby controlling psychotic manifestations

A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse, Can I vote in the upcoming presidential election? Which of the following responses should the nurse offer? A. Why do you want to vote? B. I wouldn't worry about voting right now C. We can work together to find out how you can get a mail in ballot D. You'll have a lot more opportunities to vote after you get better

C. We can work together to find out how you can get a mail in ballot

A nurse is assessing a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A. I thought i heard something too B. Is someone telling you something? C. What are you hearing? D. There is nobody in that chair for you to listen to

C. What are you hearing? Allows the nurse to find out what the client is hearing without validating the hallucination as real

A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? A. Absence of bowel sounds in all abdominal quads B. Passage of blood-tinged liquid stool C. Presence of flatus D. Hyperactive bowel sounds above the obstruction

D. Hyperactive bowel sounds above the obstruction

A nurse is caring for a client with BPH who has a new RX for doxazosin. Which of the following manifestations should the nurse monitor for as an adverse effect of doxazosin? A. seizures B. Tachycardiac C. Bronchodilation D. Hypotension

D. Hypotension

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation labs B. Apply pneumatic compression boots C. Request referral for speech D. Keep the client NPO

D. Keep the client NPO - stroke patients are at risk for aspiration ABCS!!!!

A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication? A. Urine specific gravity B. Urine output C. Blood pressure D. Temperature

D. Temperature Antipsychotic medications can cause agranulocytosis, which is the depletion of WBCs which increases the risk for infection. A fever is an early detection to check WBC

A nurse is caring for a client who has schizophrenia. The client states Aliens came into my room last night and took a sample of my blood. Which of the following responses should the nurse make? A. Aliens do not exist B. HAs your daughter had her baby C. Do you mean o say a lab tech came and drew your blood last night D. That does not sound real

D. That does not sound real This statement allows for the client to expand upon the earlier statement, which allows exploration of the clients thought process

A nurse is caring for a client who has schizophrenia and is admitted to the mental health unit. The client has history of aggression and is observed continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make? A. Its a beautiful day outside. Lets take a walk B. Sit down and we'll try try out a relaxation exercise C. Would you like you anti anxiety medication now D. You are pacing back and forth. Can you tell me what you are feeling?

D. You are pacing back and forth. Can you tell me what you are feeling?

A nurse is administering medications to a client who is recovering from a stroke and has right sided paralysis. The nurse places the clients medication on the left side of the mouth and administers pills one at a time. Which of the following ethical princiiples is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. JUstice

B. Nonmaleficence - duty to do no harm and to protect cleints from harm by eliminating threats. - the actions by the nurse are important for the safety of the client by preventing aspiration

A nurse is caring for a client who has a stroke and requires assistance performing ADLS. THe nurse should collaborate with which of the following members of the interprofessional care team? A. Speech B. OT C. Social worker D. Dietitian

B. OT

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by non-rebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute RDS? A. Temp of 38c B. PaO2 50 C. Rhonchi D. Hypopnea

B. PaO2 50 - client who has manifestations of ARDS has a lower PaO2 level. Hypoxemia after treatment with oxygen is a manifestation of ARDS

A nurse is a member of quality improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? A. paralysis of a clients lower extremities occurred following epidural B. A client fall during ambulation did not result in client injury C. A clients family member complained that a nurse was culturally insensitive D. Surgery to the wrong site was stopped prior to a procedure

A. paralysis of a clients lower extremities occurred following epidural

A nurse is planning care for a client who had a stroke. THe client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hours B. Limit the clients daily fluid intake C. Request an indwelling catheter D. Ambulate the client to the bathroom every 30 mins

A. Offer the client a bedpan every 2 hours

A nurse is creating a plan of care for a group of clients. Which of the following interventions is the priority for the nurse to include? A. Offering high calorie beverages to a client who is in the manic phase of bipolar B. Practicing relaxation techniques with a client who has an anxiety disorder C. Assisting a client who has a depressive disorder with decision making regarding group activities D. Providing teaching to a client who has schizophrenia about a new prescription for clozapine

A. Offering high calorie beverages to a client who is in the manic phase of bipolar Address the clients physiological need for food and water first aka Basic needs

A nurse is caring for a client who has schizophrenia and a prescription for chlorpromazine. For which of the following adverse effects should the nurse monitor? A. Orthostatic hypotension B. Diarrhea C. Urinary Frequency D. Bradycardia

A. Orthostatic hypotension

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 mins the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborns glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for penylketouria

A. Perform a heel stick to check the newborns glucose level

A nurse is assesing a client who reports using several herbal and vitamin supplements daily. The nurse should recognize that saw palmetto is a supplement used by clients to elicit which of the following therapeutic effects? A. Urinary health promotion B. Immune system stimulation C. Decreased leg pain from arterial disease D. Prevention of nausea caused by motion sickness

A. Urinary health promotion

A nurse is teaching a group of newly licensed nurses about violations of client rights. Which of the following examples of a violation of client rights should the nurse include the teaching? A. A client who is confused and recovering from sx has mitten restraints placed to prevent disruption of an abdominal wound. B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at the nurse of the opposite sec C. A health care proxy releases the medical records of a client to a long term care facility for a placement evaluation D. The parents of a 16-year who has gunshot wounds decide to limit their child's visitors to family members only

B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at the nurse of the opposite sex - Seclusion is for patients demonstrating violent or self destructive behavior

A nurse is caring for a client who has schizophrenia and started taking a 1st gen antipsychotic 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify whether the client is experiencing which of the following adverse effects of antipsychotic medications? A. Neuroleptic malignant syndrome B. Akathisia C. Anticholinergic toxicity D. Opisthotonos

B. Akathisia Akathisia is an extra pyramidal affect that can occur within 2 months of starting 1st gen antipsychotic

A nurse is developing a plan of care for a client after a recent stroke who has a hx of GERD. Which of the following disorders should the nurse plan to monitor this client? A. Duodenal ulcer disease B. Aspiration pneumonia C. Viral pneumonia D. Esophageal varices

B. Aspiration pneumonia

A nurse is conducting dietary teaching with a client who has a history of renal calculi. Which of the following instructions should the nurse include in the teaching? A. Consume foods containing vitamin C B. Drink 3.8L of water throughout the day C. Suggest almonds as a snack D. Limit sodium intake to 3 g per day

B. Drink 3.8L of water throughout the day - helps keep the urine diluted and decrease the risk of kidney stone formation

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Altered level of consciousness B. Impaired judgement C. Rapid change in personality D. Disturbances in perception

B. Impaired Judgement Impaired judgement occurs in clients who have dementia as they lose their ability to reason, think abstractly, and have rational thoughts.

A nurse is caring for a client who is receiving chlorpromazine to treat schizophrenia. Which of the following statements by the client should prompt the nurse to notify the provider immediately? A. My last bowel movement was 2 days ago B. My tongue keeps moving like a worm C. I feel dizzy when I stand up too quickly D. I can't stop blinking when I'm in the sun

B. My tongue keeps moving like a worm - Involuntary tongue movement indicates that this client is at greatest risk for tardive dyskinesia

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. Renal agenesis -oligohydramnios is a volume of amniotic fluid that is < 300mL during the 3rd trimster

A nurse is teaching a client who has schizophrenia about involuntary commitment. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. My family cannot commit me because I am homeless B. Even when I'm calm, I'll be forced to take psychotropic medication C. At least 2 doctors must support the commitment D. I am afraid the doctors will make me have surgery

C. At least 2 doctors must support the commitment Involuntary commitment is a court ordered mandate requiring admission of a client to receive mental health services

A nurse is performing an admission assessment for a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make? A. Please try to focus on our conversation B. There is nothing over there except a chair C. Tell me what your are seeing by that chair D. Whatever you are seeing by that chair is not real

C. Tell me what your are seeing by that chair

A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A. A tornado is going to wipe us all out B. My brain is dead, and my body is slowly rotting away C. The government is after me because I know top secret information D. The TV is purposely playing commercials for products I don't like

C. The government is after me because I know top secret information

A nurse is planning care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client? A. Skin will remain intact during hospitalization B. Verbalize one new word each week C. Will begin to help turn himself in bed D. Airway will remain clear as evidenced by clear breath sounds

D. Airway will remain clear as evidenced by clear breath sounds

A nurse is collecting data from a client with schizophrenia who was recently admitted to acute care. Which of the following findings should the nurse expect? A. Seductive behaviors B. Obsession with rituals C. Uncontrolled appetite D. Associative looseness

D. Associative looseness

A nurse is observing a client with schizophrenia in the dayroom. Another client asks him if several items of clothing match. Patient replies " A match. I like matches. They are the givers of light, the light of the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations? A. Clang association B. Echolalia C. Word salad D. Associative looseness

D. Associative looseness a pattern of disordered speech that reflects haphazard and illogical thoughts

A nurse is caring for a client who has schizophrenia. Which of the following statements indicates clang associations? A. I am the king, and everyone should bow to me B. I'm feeling schoomoolizious today C. Option, contrary, moose, allergic D. Basketball in the hall very tall

D. Basketball in the hall very tall

A nurse is caring for a 2 year old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activites would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks

D. Building towers with blocks

A nurse is providing teaching to a class about TIAs. Which of the following pieces of information should the nurse include in the teaching? A. TIA can cause irreversible hemiparesis B. Can be the result of cerebral bleeding C. Cerebral edema D. Can precede an ischemic stroke

D. Can precede an ischemic stroke

A nurse is caring for a client with schizophrenia who is having command hallucinations. Which of the following actions is the priority for the nurse to take? A. Identify triggers that initiate the client's hallucinations B. Administer an antipsychotic medication C. Focus on reality-based orientation D. Determine what the voices are saying

D. Determine what the voices are saying

A nurse is caring for a client who is 12 hrs post-po following a total hip arthroplasty. Which of following medications should the nurse anticipate to administer to this client to prevent DVT? A. Aspirin B. Warfarin C. Ticagrelor D. Enoxaparin (Heparin)

D. Enoxaparin (Heparin)

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. extended periods of sleep B. poor muscle tone C. RR 50 D. Exaggerated reflexes

D. Exaggerated reflexes - exhibits clinical findings of hyperactivity within the CNS

A nurse is caring for a client who has schizophrenia. The client tells the nurse that he is hearing voices in his head telling him to purchase a knife today. He knows that this knife will make him do bad things. which of the following responses should the nurse make? A. Why do you think the voices want you to buy a knife? B. Do you already own any knives C. When the voices speak, do you always do what they say? D. I dont hear any voices, just yours and mine. But I understand that you are fearful

D. I dont hear any voices, just yours and mine. But I understand that you are fearful

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experienced no ill effect from the error. What is the purpose of completing the incident report? A. Alerting the facility administration of a possible litigation situation B. Tracking employee performance for possible disciplinary action C. Providing a detailed report of the occurrence for the client's families D. Identifying situations that contribute to the occurrence of medication errors

D. Identifying situations that contribute to the occurrence of medication errors

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A Can you tell me why you do not want to participate int he planned group activity B. Do you understand that psychotropic medications cause weight gain C. The aerobics class will be more effective at burning calories than walking D. It sounds like you have come up with an alternative exercise that works for you

D. It sounds like you have come up with an alternative exercise that works for you

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? A. Prevent depression in the client B. Refer the client to OT C. Support the family of the client D. Monitor the client for increased intracranial pressure

D. Monitor the client for increased intracranial pressure

A nurse is assessing a client who has schizophrenia. The client states " I need to get my gummamoshu from by my house". The nurse recognizes this statement as an example of which of the following? A. Flight of ideas B. Echolalia C. Perseveration D. Neologism

D. Neologism

A nurse is planning care for a client who has aphasia following a stroke. Which of the following actions should the nurse take? A. Avoid the use of facial gestures when speaking to the client B. Speak to the client in a loud tone C. Use child like phrases to help the client understand commands D. Offer pictures for the client to point to as an alternative form of communication.

D. Offer pictures for the client to point to as an alternative form of communication.

A nurse is caring for a pregnant client who is 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. perform an amnioinfusion D. Prepare for delivery of the infant

D. Prepare for delivery of the infant - delivery is considered when a biophysical score is lower than 6

A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of QSEN initiative? A. Safety B. Informatics C. Patient-centered care D. Quality improvement

D. Quality improvement

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect A. Spasticity of the left foot B. Negative babinski reflex C. Ocular HTN D. Right sided hemiplegia

D. Right sided hemiplegia

A nurse in an acute mental health facility is reviewing the medication records of a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses? A. Postpartum depression B. Schizophrenia C. Obesity D. Severe Alzheimer's

D. Severe Alzheimer's Medication is an NMDA receptor agonist, it slows the progression of manifestations and improves cognitive functions

A nurse is providing teaching to the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A. We will not set time limits for discussing her delusions B. We will avoid reacting to her command hallucinations C. She might lose weight due to her medications D. She might be having a relapse if she stops attending social events.

D. She might be having a relapse if she stops attending social events

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. Impaired Memory C. Dysphoria (state of unease) D. Social Discomfort

D. Social discomfort Negative symptom is the absence of something that should be present

A nurse is caring for a client who has schizophrenia and is being discharged from an acute mental health setting. Which of the following should be included in the discharge plan? A. Refer the client to respite care services B. Provide a list of primary preventive mental health groups C. enroll the client in a 12 step program D. contact an intensive outpatient program

D. contact an intensive outpatient program

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. blurred vision B. Urinary retention C. Muscle flaccidity D. elevated temperature

D. elevated temperature S/S rigidity, sweating, dysrhythmias, and fluctuations in blood pressure