Final NUR 103

A client suspects an allergy to latex. When gathering data from the client, which questions would be appropriate for the nurse to ask? Select all that apply. "Are you allergic to dairy products?" "Are you allergic to bananas?" "Are you allergic to kiwi?" "Are you allergic to chestnuts?" "Are you allergic to avocados?"

"Are you allergic to bananas?" "Are you allergic to kiwi?" "Are you allergic to chestnuts?" "Are you allergic to avocados?"

A hospitalized child is to receive 75 mg of acetaminophen for fever control. How much will the nurse administer if the acetaminophen concentration is 40 mg per 0.4 ml? Record your answer using two decimal places.

0.75 mL

The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.

45mg

The nurse is reinforcing education for a female client paralyzed from a spinal cord injury (SCI). Which statement made by the client demonstrates understanding of the education? A. "I may begin to menstruate within 3 months following my injury." B. "I should use birth control pills as a means of contraception." C. "It is just as safe for me to become pregnant without an SCI." D. "I should use a tampon instead of a feminine pad when I am menstruating."

A. "I may begin to menstruate within 3 months following my injury."

The nurse is reinforcing discharge instructions for a client who received a mechanical heart valve. Which statement made by the client indicates to the nurse that instructions are understood? A. "I will have to take lifelong anticoagulation therapy." B. "My valve will have to be replaced within 10 years." C. "I will not be able to exercise or participate in previous activities." D. "I will have to be on immunosuppressant therapy for the duration of my life."

A. "I will have to take lifelong anticoagulation therapy."

A client having an implantable cardioverter-defibrillator asks the nurse, "What should I do if I feel a shock and am alone?" Which is the best response by the nurse? A. "Lie down and call 911." B. "Continue previous activity." C. "Chew an aspirin tablet." D. "Take an extra dose of your antiarrhythmic medication."

A. "Lie down and call 911."

A sexually active 22-year-old woman client arrives in the clinic for a wellness visit. Which procedure will the nurse prepare this client for? A. A Pap smear B. A chest x-ray C. A CT scan of the abdomen D. A barium enema

A. A Pap smear

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. When reviewing the client's chart, the nurse expects to find which documentation that confirms the client has Myasthenia gravis? A. A positive edrophonium (Tensilon) test B. Kernig's sign C. A positive sweat chloride test D. Brudzinski's sign

A. A positive edrophonium (Tensilon) test

When auscultating the heart of a client with pericarditis, which finding should the nurse anticipate reporting? A. A rub B. Murmur C. Gallop D. Second heart sound

A. A rub

A client with quadriplegia is in spinal shock. What should the nurse expect? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities

A. Absence of reflexes along with flaccid extremities

A client arrives in the emergency department reporting severe hives and wheezing after eating shrimp. The nurse observes the client experiencing symptoms of laryngeal edema. Which is the priority action by the nurse? A. Administer epinephrine. B. Administer montelukast (Singulair). C. Administer loratadine (Claritin). D. Administer pseudoephedrine (Sudafed).

A. Administer epinephrine.

A client is diagnosed with pulmonary edema and having pink, frothy sputum and crackles in both lungs. Which nursing intervention would be provided at this time? Select all that apply. A. Administer morphine sulfate as ordered. B. Administer furosemide (Lasix) as ordered. C. Place the legs in a dependent position. D. Administer oxygen as ordered. E. Place the client in high Fowler position.

A. Administer morphine sulfate as ordered. D. Administer oxygen as ordered. E. Place the client in high Fowler position.

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first? A. Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. B. Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting prescribed doses. C. Observe the client or a family member administer the drug to determine possible contamination sources. D. Advise the client to keep the container closed tightly and protected from light.

A. Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.

The nurse is applying a moist heat compress to a client's lower extremity. Which action by the nurse is a priority in order to prevent skin maceration? A. Apply a thin layer of petroleum jelly prior to compress application. B. Wrap the moist compress with an occlusive dressing. C. Apply the moist dressing continuously for 24 hr. D. Place a warm blanket over the dressing.

A. Apply a thin layer of petroleum jelly prior to compress application.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. A. Assist the client to the floor. B. Turn the client to the side. C. Place a pillow under the client's head. D. Give the prescribed dose of oral phenytoin. E. Insert an oral suction device to remove secretions in the mouth.

A. Assist the client to the floor. B. Turn the client to the side. C. Place a pillow under the client's head.

A client is undergoing photodynamic therapy. Which education would the nurse reinforce to prevent complications? A. Avoid direct sunlight and bright indoor lighting for 6 weeks. B. Maintain isolation for 6 weeks. C. Apply antibiotic cream to the area after treatment. D. Drink ten 8-oz glasses of fluids per day.

A. Avoid direct sunlight and bright indoor lighting for 6 weeks.

Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living? A. Avoid striped wallpaper and ceiling fans. B. Let the child sleep alone to prevent sleep interruption. C. Include extended periods of intense physical activity daily. D. Allow the child to drink soda only between noon and 5 p.m.

A. Avoid striped wallpaper and ceiling fans.

A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed? A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning

A. Body temperature control

A client who sustained head trauma in a motor vehicle crash is determined to have an increase in intracranial pressure (ICP). Which complications related to an increase in ICP should the nurse be aware of? Select all that apply. A. Brain hypoxia B. Herniation of the brain C. Brain compression D. Paralysis of the lower extremities E. Urinary retention

A. Brain hypoxia B. Herniation of the brain C. Brain compression

A client injures his or her spinal cord in a diving accident. Which cerebral vertebral level would the nurse associates the injury site if the client is unable to breathe spontaneously? A. C4 B. C5 C. C6 D. C7

A. C4

The nurse is collecting data on a geriatric client with senile dementia. When reviewing this client's file, which neurotransmitter condition is the nurse likely to find in the client's history as a contributory factor to his or her cognitive changes? A. Decreased acetylcholine level B. Increased acetylcholine level C. Increased norepinephrine level D. Decreased norepinephrine level

A. Decreased acetylcholine level

Prior to having a guaiac test performed, which instruction(s) would the nurse provide to the client? Select all that apply. A. Do not take more than 250 mg/day of vitamin C. B. Avoid taking acetylsalicylic acid (Aspirin) or NSAIDs 3 days before the test. C. Avoid eating rare red meat prior to testing. D. Do not take antihypertensive medication prior to testing. E. Avoid dairy products prior to testing.

A. Do not take more than 250 mg/day of vitamin C. B. Avoid taking acetylsalicylic acid (Aspirin) or NSAIDs 3 days before the test. C. Avoid eating rare red meat prior to testing.

The nurse is caring for a client with left lower lobe pneumonia. Which nursing action would assist in improving oxygen delivery to the lungs and tissues? A. Encourage frequent coughing and deep breathing. B. Position the client with the head of the bed slightly elevated. C. Provide deep endotracheal suctioning. D. Use a bag valve mask to ventilate the client.

A. Encourage frequent coughing and deep breathing.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention? A. Evaluation of the corneal reflex response B. Examination of the fundus of the eye C. Assessment of the client's gait D. Evaluation of bowel and bladder functions

A. Evaluation of the corneal reflex response

The rescue squad brings into the emergency department a client who has a blocked airway after choking on a piece of steak. The client is unresponsive, and resuscitation efforts are continued with a bag valve mask. Which action by the nurse is a priority? A. Gather equipment for an emergency tracheotomy. B. Intubate the client. C. Start an intravenous infusion. D. Perform a blind finger sweep.

A. Gather equipment for an emergency tracheotomy.

A nurse is caring for a client diagnosed with Alzheimer's disease who scored a 7 (high risk) on the Hendrich II Fall Risk Model. Which nursing intervention should the nurse implement? Select all that apply. A. Implement a bed alarm. B. Request a low-dose sedative. C. Instruct the client to ask for help before ambulating. D. Maintain the bed in the lowest position. E. Offer toileting every 2 to 3 hours. F. Advise family to notify staff when leaving.

A. Implement a bed alarm. D. Maintain the bed in the lowest position. E. Offer toileting every 2 to 3 hours. F. Advise family to notify staff when leaving.

The nurse is preparing to apply an ACE bandage to a client's left ankle after the client has been walking. Which action would the nurse prioritize? A. Instruct the client to lie down for 15 min before wrapping. B. Have the client sit in a chair with the foot dangling before wrapping. C. Apply warm compresses to the ankle before wrapping. D. Begin wrapping from the knee to the toes.

A. Instruct the client to lie down for 15 min before wrapping.

What is the function of cerebrospinal fluid (CSF)? A. It cushions the brain and spinal cord. B. It acts as an insulator to maintain a constant spinal fluid temperature. C. It acts as a barrier to bacteria. D. It produces cerebral neurotransmitters.

A. It cushions the brain and spinal cord.

A client is taking methotrexate (Otrexup) for the treatment of rheumatoid arthritis. What expected finding does the nurse observe when reviewing laboratory results? A. Low neutrophil count B. Low hemoglobin C. Elevated leukocyte count D. Elevated sedimentation rate

A. Low neutrophil count

An older adult client has a decrease in the number of T cells and B cells. Which nursing action is a high priority for this client? A. Monitor for signs of infection. B. Give warm blankets and keep the room warm. C. Encourage the client to eat six small meals a day. D. Obtain strict intake and output.

A. Monitor for signs of infection.

A client is diagnosed with a conductive hearing loss. After performing the Weber's test, where will the nurse document that this client heard sounds? A. On the affected side by bone conduction B. On the unaffected side C. Longer through bone than air conduction D. By neither air nor bone conduction

A. On the affected side by bone conduction

The nurse is assisting a visually impaired client with meals. Which nursing interventions will assist the client with maintaining independence and dignity? Select all that apply. A. Place food in the same "clock position" on the plate. B. Tell the client what is being served. C. Feed the client so food will not spill. D. Tell the client where food is located. E. Prepare finger foods so the client will not have to use utensils.

A. Place food in the same "clock position" on the plate. B. Tell the client what is being served. D. Tell the client where food is located.

The nurse is to obtain a urine specimen from a client who is suspected of having a urinary tract infection. After collecting and labeling the specimen, which action would the nurse take to prevent contamination of the specimen? A. Place the specimen in a biohazard bag. B. Take the specimen and place it in the laboratory refrigerator. C. Call the laboratory to come and get the specimen. D. Inform the client that the results will be back soon.

A. Place the specimen in a biohazard bag.

A nurse is positioning a client with flaccid left-sided hemiparesis in bed following a cerebral vascular accident (CVA). Which is the nurse's best intervention? A. Position the left arm supported on a pillow. B. Provide full range of motion for all extremities. C. Gently stretch the right arm. D. Exercise the limbs every 8 hours.

A. Position the left arm supported on a pillow.

A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Prepare to assist with ventilation. B. Monitor the client's heart rhythm. C. Prepare for gastric lavage. D. Obtain urine for drug screening.

A. Prepare to assist with ventilation.

The nurse is caring for a client who is intubated and mechanically ventilated. Which is a priority nursing intervention? A. Provide oral care every 2 hr. B. Suction the client every hour. C. Apply petroleum jelly to the lips to prevent dryness. D. Deflate the cuff and reposition the tube.

A. Provide oral care every 2 hr.

A nurse is preparing a client with suspected herniated nucleus pulposus (HNP) for myelography. Which nursing intervention should the nurse perform before the test? A. Question the client about allergy to iodine. B. Mark distal pulses on the foot in ink. C. Check and document pain along the sciatic nerve. D. Tell the client to cough or pant to clear the dye.

A. Question the client about allergy to iodine.

The charge nurse is observing a new graduate providing care to a client who is HIV positive. Which action by the new graduate would require immediate intervention by the charge nurse? A. Recapping a needle after giving an injection B. Using gloves when changing a soiled dressing C. Wearing a face shield when irrigating a sacral wound D. Discarding gloves when exiting the client's room

A. Recapping a needle after giving an injection

The nurse is assisting a client with chest tubes to the bedside commode when the tube becomes disconnected and falls on the floor. Which is the priority action by the nurse? A. Reconnect the tubing. B. Double-clamp tube close to the chest wall. C. Allow the client to ambulate to the bathroom. D. Place the client in the supine position.

A. Reconnect the tubing.

The nurse observes a client with a heart rate of 76 beats per minute. Where does the nurse identify the heartbeat originates? A. Sinoatrial node (SA) B. Atrioventricular node (AV) C. Bundle of His D. Purkinje fibers

A. Sinoatrial node (SA)

When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include? A. Suction for 10 to 15 seconds at a time. B. Regulate the suction machine to 300 cm suction. C. Apply suction to the catheter during insertion only. D. Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm.

A. Suction for 10 to 15 seconds at a time.

A client suffers a stroke located in the medulla. Which is the priority action by the nurse? A. Support the client's respiratory function. B. Assist the client with ambulation. C. Orient the client to surroundings frequently. D. Monitor the client for swallowing food and fluid.

A. Support the client's respiratory function.

The nurse is determining the location of the point of maximal impulse for a client during an examination. Where will the nurse place the stethoscope? A. The mediastinum B. The apex of the heart C. The right lower sternal border D. The left upper sternal border

A. The mediastinum

The nurse is assigned to care for a child with spina bifida that requires routine urinary catheterization. Which priority action by the nurse is important to prevent complications caused by an IgE-mediated reaction? A. The use of nonlatex gloves for all procedures. B. Administer epinephrine prior to performing the procedure. C. Administer diphenhydramine (Benadryl) every 4 hour to prevent an allergic reaction. D. Ensure that the child does not receive antibiotics.

A. The use of nonlatex gloves for all procedures.

The nurse is teaching a client with human immunodeficiency virus (HIV) to understand the importance of medication adherence. Which information would the nurse include when reinforcing the education? Select all that apply. A. The use of pill containers and calendars B. Interaction with foods and other drugs C. Management of medication side effects D. Obtaining refills on time E. When to discontinue medications

A. The use of pill containers and calendars B. Interaction with foods and other drugs C. Management of medication side effects D. Obtaining refills on time

The nurse is collecting data from a client with a bandage on the lower extremity. Which observations made by the nurse should be immediately reported to the charge nurse or provider? A. Toes are cold to touch. B. Toes are cyanotic. C. Toes are pink and warm. D. Edema is present in the foot and toes. E. Diminished pulses distal to the bandage.

A. Toes are cold to touch. B. Toes are cyanotic. E. Diminished pulses distal to the bandage.

A client is receiving radiation therapy for the treatment of breast cancer. Which information would the nurse provide the client to prevent skin damage during treatments? Select all that apply. A. Use only tepid water on the skin. B. Use baby shampoo to wash the skin. C. Wear cotton clothing next to the skin. D. Do not use heating or cooling devices next to the skin. E. Use at least an 8 SPF sunscreen when going outdoors.

A. Use only tepid water on the skin. C. Wear cotton clothing next to the skin. D. Do not use heating or cooling devices next to the skin.

The nurse is caring for a client with herpes zoster. Which priority measures to avoid cross-contamination would the nurse provide? A. Use transmission-based precautions. B. Administer antiviral medications as ordered. C. Apply antihistamine cream to the lesions. D. Instruct the client to wear gloves.

A. Use transmission-based precautions.

Which information would the nurse provide to the client about prevention of cataract formation? Select all that apply. A. Wear sunglasses when outside with amber, orange, or brown lenses. B. Do not stare at a computer screen for prolonged periods of time. C. Instill saline drops twice daily into both eyes. D. Make sure eyeglasses fit well. E. Wear contact lenses rather than glasses.

A. Wear sunglasses when outside with amber, orange, or brown lenses. B. Do not stare at a computer screen for prolonged periods of time.

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy? A. a 30-year-old client with schizophrenia taking chlorpromazine B. a 50-year-old client taking nitroglycerin tablets for angina C. a 60-year-old client taking prednisone for chronic obstructive pulmonary disease (COPD) D. a 75-year-old client using naproxen for rheumatoid arthritis

A. a 30-year-old client with schizophrenia taking chlorpromazine

A client has a phenytoin level of 32 mg/dl. Which symptoms should the nurse monitor based on the result? A. ataxia and confusion B. sodium depletion C. tonic-clonic seizure D. urinary incontinence

A. ataxia and confusion

The nurse is caring for a child with meningitis receiving IV fluids. What condition should the nurse monitor for closely? A. cerebral edema B. renal failure C. left-sided heart failure D. cardiogenic shock

A. cerebral edema

A young child has had multiple ear infections and is brought to the clinic screaming and holding the right ear. Which most common complication related to acute otitis media does the nurse expect this client is experiencing? A. eardrum perforation B. hearing loss C. meningitis D. tympanosclerosis

A. eardrum perforation

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: A. electromyography (EMG). B. Doppler scanning. C. Doppler ultrasonography. D. quantitative spectral phonoangiography.

A. electromyography (EMG).

Which nursing intervention should be used to prevent footdrop and contractures in a client recovering from a subdural hematoma? A. high-top sneakers B. low-dose heparin therapy C. physical therapy consultation D. sequential compression device

A. high-top sneakers

A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program? A. intermittent catheterization B. Kock pouch C. transurethral prostatectomy D. ureterostomy

A. intermittent catheterization

The nurse is working on a surgical floor. The nurse must logroll a client following a: A. laminectomy. B. thoracotomy. C. hemorrhoidectomy. D. cystectomy.

A. laminectomy.

When obtaining the health history from a client with retinal detachment, the nurse expects the client to report: A. light flashes and floaters in front of the eye. B. a recent driving accident while changing lanes. C. headaches, nausea, and redness of the eyes. D. frequent episodes of double vision.

A. light flashes and floaters in front of the eye.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: A. raccoon eyes and Battle's sign. B. nuchal rigidity and Kernig's sign. C. motor loss in the legs that exceeds the loss in the arms. D. pupillary changes.

A. raccoon eyes and Battle's sign.

The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with: A. thymus gland hyperplasia. B. poor nutrition. C. chemotherapy. D. a viral infection.

A. thymus gland hyperplasia.

A nurse working on a surgical floor observes an unlicensed assistive personnel (UAP) completing assigned tasks. Which situation requires the nurse to intervene? A. turning a client who is 24 hours post-op laminectomy B. bathing a bedridden client who has bilateral leg amputations C. assisting a client who is 16 hours post-op hemorrhoidectomy out of bed D. repositioning a client who is 12 hours post-op partial hysterectom

A. turning a client who is 24 hours post-op laminectomy

A client at the eye clinic reports difficulty seeing at night. Which nutritional deficiency should the nurse be sure the client is monitored for? A. vitamin A B. vitamin B6 C. vitamin C D. vitamin K

A. vitamin A

A client was diagnosed with having right subarachnoid hemorrhage. The nurse should plan to place the client in which position? A. with the head of the bed elevated B. on the right side C. on the left side D. flat in bed

A. with the head of the bed elevated

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? A. "Avoid taking daytime naps." B. "Avoid hot baths and showers." C. "Limit your fruit and vegetable intake." D. "Restrict fluid intake to 1,500 ml/day."

B. "Avoid hot baths and showers."

The nurse is reinforcing education for a client with hypertension. Which statement made by the client indicates that further education is required? A. "I will apply methods to reduce stress in my life." B. "I don't have to take my antihypertensives if I am feeling well." C. "I will reduce the cholesterol and salt intake in my diet." D. "I will measure my blood pressure routinely at home."

B. "I don't have to take my antihypertensives if I am feeling well."

The nurse is reinforcing education prior to discharge for a client that has had a kidney transplant. Which statement made by the client indicates that education about rejection is understood? A. "I will take a laxative if I am unable to have a bowel movement." B. "I will report fever, chills, and profuse sweating to the primary care provider." C. "I will take my immunosuppressant drugs whenever I feel I am developing an infection." D. "I don't have to see my nephrologist any longer since I am cured of kidney disease."

B. "I will report fever, chills, and profuse sweating to the primary care provider."

The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the most accurate? A. "Clonic seizure activity is usually interpreted as falling." B. "It's not unusual to develop seizures after a head injury because of brain trauma." C. "Focal discharge in the brain may lead to absence seizures that go unnoticed." D. "The brain needs multiple stimuli before it manifests as a seizure."

B. "It's not unusual to develop seizures after a head injury because of brain trauma."

A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication? A. "The medication will help dilate the pupils of my eyes." B. "The medication will help decrease pressure in my eyes." C. "The medication will prevent eye infection." D. "The medication will prevent eye movement."

B. "The medication will help decrease pressure in my eyes."

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. When asked by the newly graduated nurse, what type of hearing loss it is, how would the nurse preceptor respond? A. "It is considered a functional hearing loss." B. "This type of loss is a fluctuating hearing loss." C. "This is considered a sensorineural hearing loss." D. "This type of loss is a conductive hearing loss."

B. "This type of loss is a fluctuating hearing loss."

A client undergoing chemotherapy states to the nurse, "I am ready to give up. I can't take this anymore." Which is the most therapeutic response by the nurse? A. "I will let your primary care provider know you are canceling your chemotherapy." B. "You sound discouraged. Would you like to talk about it?" C. "What is the problem with the chemotherapy?" D. "You need to ask your family what you should do."

B. "You sound discouraged. Would you like to talk about it?"

A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client? A. A private room down the hall from the nurses' station B. An isolation room close to the nurses' station C. A semiprivate room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis

B. An isolation room close to the nurses' station

The nurse is caring for a client who was hit in the left eye with a softball. The eye is edematous and painful to touch. Which is the priority intervention by the nurse? A. Apply a cold pack. B. Apply a warm compress. C. Have the client lay flat for 12 hr to decrease swelling. D. Place drops in the eye to decrease pain.

B. Apply a warm compress.

A client arrives in the emergency department after being bitten by a raccoon that wandered into the yard. The nurse should anticipate administering a rabies vaccine to provide which type of immunity? A. Naturally acquired active immunity B. Artificially acquired passive immunity C. Antibody-mediated immunity D. Naturally acquired passive immunity

B. Artificially acquired passive immunity

The nurse is preparing a client with colon cancer for palliative surgery. Which outcome does the nurse expect for this client? A. Complete recovery B. Better quality of life C. Damage to cancer cells D. Remission

B. Better quality of life

After applying a bandage to the upper right extremity, which action would the nurse take next? A. Administer medication for pain. B. Check the circulation of the client's fingers. C. Provide instructions for care. D. Document the application of the bandage.

B. Check the circulation of the client's fingers.

The nurse is reviewing the medical record for a client in a long-term care facility. The nurse notes an entry by the primary care physician indicating the client is colorblind. The nurse understands this condition results from a problem with which structure(s) of the eye? A. Rods B. Cones C. Lens D. Aqueous humor

B. Cones

The nurse applies oxygen at 2 L/min via nasal cannula as prescribed for a client with dyspnea and an oxygen saturation of 90%. Which is a priority nursing action after oxygen administration for this client? A. Adjust the amount of oxygen flow every 4 hr. B. Continually monitor the client's respiratory status. C. Remove the oxygen cannula when ambulating in the room. D. Maintain the client in the supine position.

B. Continually monitor the client's respiratory status.

Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve will the nurse assess to determine if it is functioning so the client can chew? A. Cranial nerve II B. Cranial nerve V C. Cranial nerve IX D. Cranial nerve X

B. Cranial nerve V

The nurse is providing a tepid sponge bath for a client with a fever. When the client begins to shiver, which action by the nurse is a priority? A. Pour isopropyl alcohol into the water. B. Discontinue the bath immediately and report findings. C. Increase the temperature of the water. D. Continue the bath since this is an expected reaction.

B. Discontinue the bath immediately and report findings.

The nurse is applying an oxygen cannula to a client with pneumonia. Which information would the nurse be sure to include when reinforcing education about oxygen administration? Select all that apply. A. Use an electric razor instead of a straight razor around oxygen. B. Do not use oils around the oxygen, especially on hands. C. Avoid smoking around oxygen. D. Do not adjust the cannula after it is applied. E. Discontinue the oxygen if there is nasal dryness.

B. Do not use oils around the oxygen, especially on hands. C. Avoid smoking around oxygen. D. Do not adjust the cannula after it is applied.

The nurse is caring for a client in the clinic who is diagnosed with the common cold. Which education would the nurse reinforce to help alleviate symptoms? A. Take antibiotics as prescribed. B. Drink plenty of fluids. C. Increase activity level. D. Avoid contact with others for 2 weeks.

B. Drink plenty of fluids.

A client with a T6 injury reports a pounding headache, blurred vision, and nasal congestion. The nurse observes profuse sweating above the level of injury. Which is the priority action by the nurse? A. Irrigate the client's indwelling catheter. B. Elevate the client's head. C. Place the client in Trendelenburg position. D. Obtain the client's temperature.

B. Elevate the client's head.

A nurse is caring for a client who has sustained a closed head injury. What nursing intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)? A. Suction the airway every hour and as needed. B. Elevate the head of the bed 30 degrees. C. Turn and reposition the client every 2 hours. D. Maintain a well-lighted room.

B. Elevate the head of the bed 30 degrees.

The nurse is caring for a client with a subdural hematoma. Which is the priority outcome? A. Restore blood pressure to the normal range. B. Ensure airway patency and optimal oxygen levels and protect from injury. C. Ensure adequate nutrition, hydration, and elimination. D. Provide psychological support and maintain skin integrity and effective thermoregulation.

B. Ensure airway patency and optimal oxygen levels and protect from injury.

The nurse is caring for a client who is blind. Which is the best way for the nurse to assist with ambulation? A. Have the aide push the client in a wheelchair. B. Have the client take the nurse's arm, with the nurse walking slightly ahead of the client. C. Have the client walk beside the nurse, with the nurse's hand on the client's back. D. Have the client walk down the hall with his or her hand along the wall.

B. Have the client take the nurse's arm, with the nurse walking slightly ahead of the client.

A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings should the nurse notify the physician of because they indicate spasm or occlusion of a cerebral vessel by a clot? A. Nausea, vomiting, and profuse sweating B. Hemiplegia, seizures, and decreased level of consciousness (LOC) C. Difficulty breathing or swallowing D. Tachycardia, tachypnea, and hypotension

B. Hemiplegia, seizures, and decreased level of consciousness (LOC)

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Dressing or grooming self-care deficit

B. Ineffective breathing pattern

A client has a defective cranial nerve I. Which data would the nurse gather in order to determine function? A. Use a tuning fork to determine bone conduction. B. Instruct the client to smell and identify a variety of scents. C. Ask the client to open and close the eyes. D. Request the client to stick the tongue out and say "ah."

B. Instruct the client to smell and identify a variety of scents

A nurse is prescribed postexposure prophylaxis (PEP) antiretroviral medication after a needle stick from an HIV-positive client. Which side effect would the nurse likely experience when taking this medication? A. Fatigue B. Nausea C. Swollen lymph nodes D. Constipation

B. Nausea

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? A. Encourage the client to close his eyes. B. Notify the physician. C. Turn out the lights in the room. D. Instill artificial tears.

B. Notify the physician.

A client's chronic, progressive hearing loss results from excess bone formation around the oval window, which impedes normal stapes movement and prevents sound transmission. The nursing student is researching the disorder. What is the clinical terminology for this correctable middle ear disorder that the student would utilize in her research? A. Stapes immobilization B. Otosclerosis C. Myringotomy D. Otitis media

B. Otosclerosis

A child has just returned to the pediatric unit following ventriculoperitoneal shunt placement for hydrocephalus. Which intervention would the nurse perform first? A. Monitor intake and output. B. Place the child on the side opposite the shunt. C. Offer fluids because the child has a dry mouth. D. Administer pain medication by mouth as ordered.

B. Place the child on the side opposite the shunt.

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? A. Anxiety B. Powerlessness C. Ineffective denial D. Risk for disuse syndrome

B. Powerlessness

A client states to the nurse, "I want to quit smoking. My father had a heart attack and he was a heavy smoker." Which action by the nurse is appropriate? A. Inform the client it would be best to stop immediately without aids. B. Provide information regarding counseling and smoking cessation aids. C. Encourage the client to quit because quitting is the only way to avoid a heart attack. D. Inform the client to get a prescription for anxiety before trying to stop.

B. Provide information regarding counseling and smoking cessation aids.

Which intervention provided by the nurse would assist the client with early chronic obstructive lung disease to improve efficiency of lung function? A. Administer breathing treatment with a bronchodilator. B. Provide smoking cessation information. C. Perform chest physiotherapy. D. Encourage coughing and deep breathing.

B. Provide smoking cessation information.

Which method should the nurse use to properly instill eardrops in an adult client with otitis externa? A. Pull the pinna down and back. B. Pull the pinna up and back. C. Pull the tragus up and back. D. Separate the palpebral fissures with a clean gauze pad.

B. Pull the pinna up and back.

A client informs the nurse that he is color blind. Which colors does the nurse determine the client will likely have difficulty distinguishing? A. White and black B. Red and green C. Blue and purple D. Orange and pink

B. Red and green

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. What does this evaluation determine for the client? A. The client has alterations in near vision and is legally blind. B. The client can see at 20 feet what the person with normal vision sees at 40 feet. C. The client can see at 40 feet what the person with normal vision sees at 20 feet. D. The client has a 20% decrease in acuity in one eye and a 40% decrease in the other eye.

B. The client can see at 20 feet what the person with normal vision sees at 40 feet.

A client with chronic alcoholism and late-stage cirrhosis of the liver has significant damage to Wernicke area. Which data obtained by the nurse are indicative of this damage? A. The client is unable to ambulate independently. B. The client does not comprehend written and spoken language but speaks. C. The client has speech impairment but is able to comprehend language. D. The client's left hand is experiencing paralysis.

B. The client does not comprehend written and spoken language but speaks.

A client accidentally splashes chemicals into his eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment? A. To hasten formation of scar tissue B. To prevent vision loss C. To eliminate the need for medical care D. To serve as a stopgap measure until help arrives

B. To prevent vision loss

A nurse is taking care of four clients. Which client should the nurse see first? A. a 17-year-old client 24 hours postappendectomy B. a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome C. a 50-year-old client 3 days post-myocardial infarction (MI) D. a 50-year-old client with diverticulitis

B. a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome

One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication? A. additional pyridostigmine B. atropine C. edrophonium D. acyclovir

B. atropine

A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when A. e-mailing information about a client to a friend at home. B. documenting medications after administration. C. documenting medications before administration. D. determining a client's identity from a computer chart.

B. documenting medications after administration.

A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to? A. diplopia B. permanent vision loss C. loss of central vision D. pupillary constriction

B. permanent vision loss

A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test? A. "Do not eat anything for 12 hours before the test." B. "Do not shampoo your hair for 24 hours before the test." C. "Avoid stimulants and alcohol for 24 to 48 hours before the test." D. "Avoid thinking about personal matters for 12 hours before the test."

C. "Avoid stimulants and alcohol for 24 to 48 hours before the test."

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? A. "My family will take care of me. I've given my daughter durable power of attorney for health care." B. "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." C. "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens." D. "Signing an advance directive now will help ensure that my family and care team know what I want when I'm eventually unable to make decisions."

C. "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint? A. "Did you let them know that you needed help?" B. "When did you last have someone bathe you?" C. "I'm sorry you haven't been bathed. I'm available to bathe you now." D. "I don't understand why they didn't bathe you; they indicated during shift report that they did."

C. "I'm sorry you haven't been bathed. I'm available to bathe you now."

A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate? A. "You have a mild concussion; acetaminophen is strong enough." B. "Aspirin is avoided because of the danger of Reye syndrome in children or young adults." C. "Opioids are avoided after a head injury because they may hide a worsening condition." D. "Stronger medications may lead to vomiting, which increases intracranial pressure (ICP)."

C. "Opioids are avoided after a head injury because they may hide a worsening condition."

A client arrives at the clinic requesting testing for HIV. Which response by the nurse is best? A. "Did you have sex with multiple partners?" B. "The test results won't be back for a while." C. "You will need to sign a consent form prior to testing." D. "We will call you with the results."

C. "You will need to sign a consent form prior to testing."

Which primary care provider order would the nurse question prior to implementing? A. Use of a warm sitz bath for relief of discomfort related to a client's hemorrhoids B. Application of a warm compress to the lower back to relieve soreness after back strain C. Application of a warm compress to the abdomen of a client with suspected appendicitis D. Use of a warm compress to the lower abdomen of a woman with menstrual cramps

C. Application of a warm compress to the abdomen of a client with suspected appendicitis

A client is scheduled for a surgical procedure. When assisting with implementation of the plan of care, which action can the nurse take to reduce surgical site infection? A. Administer oxygen during the preoperative phase. B. Wash the surgical site with soap and water prior to surgery. C. Apply warm blankets. D. Use antibiotic ointment before the incision is made.

C. Apply warm blankets.

The nurse asks a client to use the eyes to follow finger movements to the left and right and then to close and open the eyes. Which cranial nerve will the nurse document as intact if the client is able to perform these movements? A. Cranial nerve I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve IV

C. Cranial nerve III

The nurse is obtaining a urine specimen from a client for a drug screen. Which is the appropriate action for the nurse to take? A. Have the client go into the bathroom and close the door to void. B. Have the client void in a urinal or bedpan and place the specimen in a container. C. Directly observe the client voiding in the specimen container. D. Give the client a cup of water to drink while in the bathroom to assist with voiding.

C. Directly observe the client voiding in the specimen container.

The nurse is reinforcing education regarding the use of eye drops during treatment for a client who has been diagnosed with conjunctivitis. Which information will the nurse provide the client? A. Warm the solution briefly in the microwave prior to use. B. Save the unused solution for use if the infection returns. C. Ensure not to touch the eye with the dropper. D. Use the drops for the other member of the family who has conjunctivitis.

C. Ensure not to touch the eye with the dropper.

The nurse is preparing to apply a large stretch-net bandage to a client's torso. Which action would the nurse perform first? A. Clean the client's skin with an alcohol-based solution to remove dead skin. B. Obtain pins or clips in order to attach the dressing. C. Explain the procedure to the client. D. Apply the bandage tightly to the torso.

C. Explain the procedure to the client.

A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints? A. Make sure that the restraints fit snuggly to restrict the client from reaching his nose, arms, or perineal area. B. Apply one wrist restraint at a time. C. Fasten the restraint to the bed frame using a quick-release knot. D. Place a sign over the client's bed warning staff to avoid removing the restraints.

C. Fasten the restraint to the bed frame using a quick-release knot.

A client is admitted with Meniere disease. Which instruction should the nurse reinforce in client teaching? A. Report dizziness at once. B. Drive in daylight hours only. C. Get up slowly, turning the entire body. D. Use logrolling technique when moving.

C. Get up slowly, turning the entire body.

The nurse is preparing a client for a bronchoscopy. Which nursing actions are essential prior to the procedure? Select all that apply. A. Administer an enema. B. Detail the complications that can occur. C. Give mouth care. D. Observe for any loose teeth. E. Explain the procedure.

C. Give mouth care. D. Observe for any loose teeth. E. Explain the procedure.

The nurse administers an "allergy shot" to a client in the clinic. Which is the nurse's priority action? A. Have the client eat a small meal. B. Administer epinephrine before discharging the client. C. Have the client wait 20 min in the clinic after the injection. D. Administer ibuprofen (Motrin) 400 mg after injection for pain.

C. Have the client wait 20 min in the clinic after the injection.

A client is suspected of having tuberculosis. When would be the best time for the nurse to collect the sputum specimen? A. After the client brushes the teeth. B. Directly before the client goes to bed in the evening. C. Immediately after the client awakens in the morning. D. After the client eats a meal.

C. Immediately after the client awakens in the morning.

A client comes to the emergency department after hitting his or her head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first? A. Perform full range of motion (ROM). B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open airway using head tilt/chin lift maneuver.

C. Immobilize the client's head and neck.

When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? A. Shock B. Encephalitis C. Increased intracranial pressure (ICP) D. Status epilepticus

C. Increased intracranial pressure (ICP)

The nurse is presenting a lecture on vertigo at a community setting. The nurse will include that the client with vertigo may have a problem with which portion of the ear? A. External ear B. Middle ear C. Inner ear D. Tympanic membrane

C. Inner ear

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take? A. Contact the social services department to make arrangements for the client to complete a living will. B. Notify the physician so that he can place a do-not-resuscitate order on the client's medical record. C. Make arrangements for the client to receive information about advance directives. D. Explain that his condition is stable, so he doesn't need to be concerned at this time.

C. Make arrangements for the client to receive information about advance directives.

A client is admitted with myasthenia gravis. Which nursing intervention should be priority? A. Observe for bleeding. B. Promote mobility. C. Monitor respiratory status. D. Prevent dehydration.

C. Monitor respiratory status.

A client has a positive tuberculin skin test. Which action by the nurse is appropriate? A. Administer another tuberculin skin test. B. Administer a tine test. C. Prepare the client for a chest x-ray. D. Prepare the client for a bronchoscopy.

C. Prepare the client for a chest x-ray.

A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the priority action by the nurse? A. Ask the client's children why the client has bruises. B. Monitor the client's condition during subsequent visits. C. Report suspicion of elder abuse to the local agency on aging. D. Order diagnostic tests including blood work and X-rays.

C. Report suspicion of elder abuse to the local agency on aging.

A client is being considered as a candidate for a cochlear implant. Which data gathered by the nurse would support the client's candidacy? A. The client has mild mental retardation. B. The client has a history of schizophrenia. C. The client is unable to recognize words spoken. D. The client expects hearing will resume normally after surgery.

C. The client is unable to recognize words spoken.

The nurse is discussing the benefits of breastfeeding to a pregnant mother. Which statement made by the client demonstrates understanding of the benefits? A. The infant will receive artificially acquired active immunity to protect the infant from viruses. B. The infant will receive artificially acquired passive immunity to protect them from diseases such as multiple sclerosis. C. The infant will receive naturally acquired passive immunity to last approximately 6 months. D. The infant will receive antibody-mediated immunity to prevent the child from acquiring respiratory disorders for 1 year.

C. The infant will receive naturally acquired passive immunity to last approximately 6 months.

The nurse witnesses a client having a tonic-clonic seizure in the bed. Which is the priority action by the nurse? A. Insert a tongue blade between the client's teeth. B. Place the client in the prone position. C. Turn the head to the side. D. Insert an indwelling catheter.

C. Turn the head to the side.

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal? A. More back pain than the first postoperative day B. Paresthesia in the dermatomes near the wounds C. Urine retention or incontinence D. Temperature of 99.2° F (37.3° C)

C. Urine retention or incontinence

A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation of the disease and requires a low-level consistent oxygen concentration. Which method of oxygen delivery will the nurse apply? A. Partial-rebreathing mask B. Nonrebreather mask C. Venturi mask D. Nasal cannula

C. Venturi mask

A client was hit in the head with a baseball during practice. Which discharge instructions should the nurse reinforce? A. Watch client for keyhole pupil for the next 24 hours. B. Expect profuse vomiting for 24 hours after the injury. C. Wake client every hour and check orientation to person, time, and place. D. Notify health care provider immediately when experiencing headache.

C. Wake client every hour and check orientation to person, time, and place.

The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures? A. extent of intracranial bleeding B. sites of brain injury C. activity of the brain D. percentage of functional brain tissue

C. activity of the brain

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: A. provide instructions on eye patching. B. assess the client's visual acuity. C. demonstrate eyedrop instillation. D. teach about intraocular lens cleaning.

C. demonstrate eyedrop instillation.

The nurse is watching the health care provider check reflexes during a physical assessment. The RN elicits a positive Babinski reflex. The nurse is aware that this reflex is characterized by what? A. supination and flexion of the forearm B. extension of the elbow and contraction of the triceps tendon C. dorsiflexion of the great toe with fanning of the other toes D. flexion of the arm at the antecubital fossa and contraction of the biceps

C. dorsiflexion of the great toe with fanning of the other toes

A client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. The client's medications include heparin and isosorbide. The nurse should monitor the client for which condition? A. dehydration B. hypocarbia C. hypotension D. tube feeding

C. hypotension

A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority? A. impaired physical mobility B. decreased gastrointestinal motility C. impaired swallowing D. risk for isolation

C. impaired swallowing

A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse rate of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition would most likely be suspected? A. autonomic dysreflexia B. hypervolemia C. neurogenic shock D. sepsis

C. neurogenic shock

While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory rate of 18 breaths/minute. The nurse suspects which condition? A. autonomic dysreflexia B. hemorrhagic shock C. neurogenic shock D. pulmonary embolism

C. neurogenic shock

The nurse is caring for a client post-transurethral resection of the prostate (TURP) with bladder irrigation. After surgery, what color would the nurse expect the urine to be? A. clear B. light yellow C. pink to dark red D. bright red

C. pink to dark red

The nurse is reinforcing education to a client taking phenytoin for the treatment of seizures. The client asks, "Can I still have my beer every day"? What is the best response by the nurse? A. "Alcohol increases phenytoin activity." B. "Alcohol raises the seizure threshold." C. "Alcohol impairs judgment and coordination." D. "Alcohol decreases the effectiveness of phenytoin."

D. "Alcohol decreases the effectiveness of phenytoin."

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B. "Try to ambulate independently after about 24 hours." C. "Shampoo your hair every day for 10 days to help prevent ear infection." D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

The nurse is discharging a client from the hospital after a laminectomy. What statement made by the client indicates that further education should be reinforced? A. "I'll sleep on a firm mattress." B. "I won't drive for 2 to 4 weeks." C. "When I pick things up, I'll always bend my knees." D. "I can't wait to toss my granddaughter up in the air."

D. "I can't wait to toss my granddaughter up in the air."

The nurse is reinforcing education for a female client, who is HIV positive, about transmission of the virus. Which statement made by the client demonstrates that further education is required? A. "If I become pregnant, I must continue to take my antiretroviral medication." B. "I should not kiss anyone while I have an open sore in my mouth." C. "I will be able to breastfeed if my baby and I are taking antiretroviral drugs." D. "I may be able to transmit HIV if someone uses a glass after I drink from it."

D. "I may be able to transmit HIV if someone uses a glass after I drink from it."

A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response? A. "St. John's wort is an herbal remedy that can be used to treat depression." B. "If you take St. John's wort and Parkinsonian drugs, take them on alternate days." C. "St. John's wort must be taken in large doses to help reduce depression." D. "St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

D. "St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response? A. "Older age at conception is one of the major causes of the defect." B. "It is a common complication of amniocentesis." C. "It has been linked to maternal alcohol consumption during pregnancy." D. "The cause is unknown, and there are many environmental factors that may contribute to it."

D. "The cause is unknown, and there are many environmental factors that may contribute to it."

An older adult client informs the nurse of a "terrible ringing in the ears." Which question would be a priority for the nurse to ask the client? A. "Do you irrigate your ears?" B. "When was the last time you had an ear examination?" C. "Does anyone in your family have this problem?" D. "What medications do you take?"

D. "What medications do you take?"

The nurse is gathering data for several clients. When obtaining pulse oximetry readings, the nurse determines that this method is ineffective for which client? A. A client on oxygen via nonrebreather mask B. A client with pneumonia C. A client with chronic obstructive pulmonary disease (COPD) D. A client with severe anemia

D. A client with severe anemia

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention would the nurse implement to reduce the client's risk of increased intracranial pressure (ICP)? A. Encouraging oral fluid intake B. Suctioning the client once each shift C. Elevating the head of the bed 90 degrees D. Administering a stool softener as prescribed

D. Administering a stool softener as prescribed

A client is preparing to have an angiocardiogram in the morning. Which data would the nurse obtain in preparation for this test? A. Ask if the client has crutches or a cane to use after the test. B. Ask if the client has a family member that had this test. C. Ask if the client has received a yearly flu shot. D. Ask if the client is allergic to shellfish or iodine.

D. Ask if the client is allergic to shellfish or iodine.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? A. Putting slippers on the client's feet B. Crossing the client's ankles every 2 hours C. Placing hand rolls on the balls of each foot D. Attaching braces or splints to each foot and leg

D. Attaching braces or splints to each foot and leg

The nurse is obtaining data from an older adult client. Which finding would the nurse recognize as consistent with "stiffening" of the large arteries? A. Respiratory rate of 18 breaths per minute B. Heart rate of 64 beats per minute C. Blood pressure of 100/60 mm Hg D. Blood pressure of 160/72 mm Hg

D. Blood pressure of 160/72 mm Hg

The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse-manager. D. Call the physician immediately.

D. Call the physician immediately.

A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the priority nursing action? A. Turn the client on the client's back. B. Ask the client when prescribed medication was last taken. C. Place the client in a darkened room and check on the client in 30 minutes. D. Check the client's vital signs and remove restrictive clothing.

D. Check the client's vital signs and remove restrictive clothing.

A client states to the nurse, "I am taking a trip by plane and the last time I flew, the problems with my ears were awful!" Which suggestion would the nurse provide to alleviate discomfort? A. Use a Q-tip to remove impacted wax to decrease pressure when flying. B. Insert saline drips into both ears every hour while flying. C. Irrigate the ear prior to the trip to remove wax and decrease pressure. D. Chew gum to promote swallowing.

D. Chew gum to promote swallowing.

A client is having a colonoscopy, and suddenly the client's heart rate drops from 72 beats per minute (BPM) to 52 BPM. Which cranial nerve does the nurse determine has been stimulated? A. Cranial nerve I (olfactory) B. Cranial nerve V (trigeminal) C. Cranial nerve IX (glossopharyngeal) D. Cranial nerve X (vagus)

D. Cranial nerve X (vagus)

A client is eating supper and begins coughing. Which action should the nurse take first? A. Insert fingers into the mouth to do a blind sweep and remove object. B. Lay the client flat and perform chest thrusts. C. Pat the client on the back to assist with dislodging the foreign body. D. Do nothing. Coughing will usually dislodge the foreign body.

D. Do nothing. Coughing will usually dislodge the foreign body.

When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize? A. Glaucoma is easily corrected with eyeglasses. B. The disorder will not lead to complete loss of vision. C. Yearly screening for people ages 20 to 40 is recommended. D. Glaucoma can be painless with loss of peripheral vision.

D. Glaucoma can be painless with loss of peripheral vision.

A client sustains a head trauma after falling from a roof. The nurse observes clear fluid leaking from the nose. What priority action should the nurse take? A. Use a Q-tip to gently clean the nasal passages. B. Pack the nose with nasal packing. C. Instruct the client to blow their nose to clear the passages. D. Have the fluid checked for glucose.

D. Have the fluid checked for glucose.

The nurse is preparing a client for abdominal surgery. Which action by the nurse can prevent postoperative atelectasis? A. Suction the client every 2 hr. B. Administer supplemental oxygen. C. Administer an inhaled bronchodilator. D. Instruct the client about the use of incentive spirometry.

D. Instruct the client about the use of incentive spirometry.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate? A. Increased intracranial pressure (ICP) B. Cerebral edema C. Low cerebrospinal fluid (CSF) pressure D. Meningeal irritation

D. Meningeal irritation

The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation? A. Check for peripheral vision. B. Touch the cornea lightly with a wisp of cotton. C. Have the client follow an object upward, downward, obliquely, and horizontally. D. Observe for pupil constriction and convergence while focusing on an object coming toward the client.

D. Observe for pupil constriction and convergence while focusing on an object coming toward the client.

A client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which nursing intervention should be done first? A. Place the client flat in bed. B. Check patency of the indwelling urinary catheter. C. Give one sublingual nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees.

D. Raise the head of the bed immediately to 90 degrees.

The client's bandage has become soiled. Which action would the nurse take to avoid spreading microorganisms? A. Place a dressing under the bandage. B. Wash the bandage to remove the drainage. C. Reinforce the bandage with another. D. Replace the bandage with a new one.

D. Replace the bandage with a new one.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A. Disturbed sensory perception (visual) B. Dressing or grooming self-care deficit C. Impaired verbal communication D. Risk for injury

D. Risk for injury

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority? A. Disturbed sensory perception (visual) related to neurologic trauma B. Feeding self care deficit: related to neurologic trauma C. Impaired verbal communication related to confusion D. Risk for injury related to neurologic deficit

D. Risk for injury related to neurologic deficit

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? A. Acute pain related to vertigo B. Imbalanced nutrition: Less than body requirements related to nausea and vomiting C. Risk for deficient fluid volume related to vomiting D. Risk for injury related to vertigo

D. Risk for injury related to vertigo

A client has a decrease in T cells and B cells. The nurse would monitor the client for which complication? A. Altered kidney function B. Blood loss C. Joint swelling and tenderness D. Signs of infection

D. Signs of infection

The nurse applies a cold pack to a client's wrist after a sprain. Which action by the nurse a priority when the client reports a burning pain at the site? A. Replace the compress with another cold compress. B. Place the wrist in hot water to reverse the cold. C. Administer an analgesic for the pain. D. Stop treatment and notify the primary care provider.

D. Stop treatment and notify the primary care provider.

The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate? A. Provide symptomatic treatment. B. Advise the parent that this is a viral infection. C. Consult the primary health care provider. D. Tell the parent to bring the child to the primary health care provider's office.

D. Tell the parent to bring the child to the primary health care provider's office.

The nurse is requested to place an ice pack on the eyelid for 2 min for a client suspected of having myasthenia gravis (MG) with diplopia. Which outcome does the nurse anticipate if the diagnosis is confirmed? A. The client will experience an improvement in respiratory status. B. The client will experience blindness. C. The client will have a grave prognosis. D. The client will have a temporary improvement in eye symptoms.

D. The client will have a temporary improvement in eye symptoms.

The primary care provider orders ear irrigation for a client. Which situation requires the nurse to question this order? A. The client has a scratch on the external canal. B. The client has a foreign body in the ear. C. The ear canal has impacted cerumen. D. The eardrum may be punctured.

D. The eardrum may be punctured.

A nurse instills atropine drops in both eyes of a client undergoing an ophthalmic examination. Which instruction should the nurse reinforce after administering the medication? A. Be careful because the blink reflex is paralyzed. B. Avoid wearing regular glasses when driving. C. It is normal to expect that the pupils may be unusually small. D. Wear dark glasses in bright light because the pupils are dilated.

D. Wear dark glasses in bright light because the pupils are dilated.

A client has a dressing on a sacral wound that is saturated with drainage. How would the nurse obtain the output information from this dressing? A. Estimate the amount of liquid in the saturated dressing. B. The information cannot be obtained since it is not liquid. C. Weigh the dressing and document the results. D. Weigh the dressing and then weigh an identical dry dressing.

D. Weigh the dressing and then weigh an identical dry dressing.

A client is newly diagnosed with myasthenia gravis. When reinforcing education what should the nurse indicate as the cause of this disease? A. a postviral illness characterized by ascending paralysis B. loss of the myelin sheath surrounding peripheral nerves C. inability of basal ganglia to produce sufficient dopamine D. destruction of acetylcholine receptors, causing muscle weakness

D. destruction of acetylcholine receptors, causing muscle weakness

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: A. genetic dysfunction. B. upper and lower motor neuron lesions. C. decreased conduction of impulses in an upper motor neuron lesion. D. destruction of acetylcholine receptors.

D. destruction of acetylcholine receptors.

A nurse is collecting data on a client who sustained a head injury after a fall from the roof. What signs and symptoms should the nurse observe the client for? A. emotional instability, vertigo, diplopia, and weakness B. memory loss, poor attention span, incontinence, and wandering C. fatigue, lack of coordination, heat intolerance, and judgment defects D. restlessness, disorientation, pupil dilation, and projectile vomiting

D. restlessness, disorientation, pupil dilation, and projectile vomiting

When communicating with a client who has sensory (receptive) aphasia, the nurse should: A. allow time for the client to respond. B. speak loudly and articulate clearly. C. give the client a writing pad. D. use short, simple sentences.

D. use short, simple sentences.