Hesi Level 1

What is High Fowler's position?

The patient is usually seated upright with their spine straight. The upper body is between 60 and 90 degrees. The legs of the patient may be straight or bent.

The nurse understands that assessment of blood pressure in clients receiving antipsychotic drugs is important. What is a reason for this assessment? A. Orthostatic hypotension is a common side effect. B. Most antipsychotic drugs cause elevated blood pressure. C. This provides additional support for the client. D. It will indicate the need to institute antiparkinsonian drugs.

A. Orthostatic hypotension is a common side effect.

While in the grocery store, a nurse is confronted by a neighbor who asks how the neighbor's hospitalized aunt is doing. The nurse decides that because she knows the neighbor well and the neighbor is related to the client, it is acceptable to tell the neighbor about the client's progress. This scenario can be seen as A. Unethical and illegal B. Appropriate because the neighbor is a relative C. Appropriate because the discussion occurred outside the work place D. Unethical, but not illegal

A. Unethical and illegal

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? A. Use the sealed and chilled milk within 24 hours. B. Use any frozen milk within 6 months of obtaining it. C. Use microwave ovens to warm the chilled milk. D. Refreeze any unused milk for later use if it has not been out more that 2 hours.

A. Use the sealed and chilled milk within 24 hours.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: 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.

Which tools do case managers commonly rely on to plan and coordinate client care? A. clinical pathways, practice guidelines, and standards of care B. clinical pathways and drug formularies C. standards of care, HIPAA regulations, and electronic medical records D. practice guidelines, outcome data, and staff rosters

A. clinical pathways, practice guidelines, and standards of care

When calling the health care provider for a telephone order, what is the nurse's initial action? A. identifying self and agency B. verifying order given C. providing situation, background, assessment, and recommendation (SBAR) information D. authenticating the prescriber's identity

A. identifying self and agency

A client with blood type B requires a blood transfusion. The siblings of this client are asked to donate blood. Two siblings have type O and one has type A blood. Which sibling will be able to donate blood? A. None of the siblings B. Both siblings with type O C. The sibling with type A D. All of the siblings

B. Both siblings with type O

What is Prone position?

The patient is lying horizontally with the face and torso facing down.

What is Supine position?

The patient is lying horizontally with the face and torso facing up.

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? A. Continuous positive airway pressure (CPAP) B. Bilevel positive airway pressure (BiPAP) C. Mechanical ventilation D. Oxygen by nasal cannula

A. Continuous positive airway pressure (CPAP)

Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client (who now has nausea) and records a temperature of 105°F (40.5°C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? A. Diabetic ketoacidosis B. Thyroid crisis C. Hypoglycemia D. Tetany

B. Thyroid crisis

A client with a musculoskeletal injury is instructed to alter the diet. The objective of altering the diet is to facilitate the absorption of calcium from food and supplements. Considering the food intake objective, which food item should the nurse encourage the client to include in the diet? A. Red meat B. Bananas C. Vitamin D-fortified milk D. Green vegetables

C. Vitamin D-fortified milk

When promoting client safety on an inpatient psychiatric unit, which interventions would be used as the measure of last resort? A. Surveillance B. Seclusion C. Room restriction D. Four-point restraint

D. Four-point restraint

Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation? A. It documents assessments on separate forms. B. It records progress under problems, intervention, and evaluation. C. It provides and refers to a client's problem by a number. D. It provides quick access to abnormal findings.

D. It provides quick access to abnormal findings.

What areas are mainly responsible for coordinating internal and external responses? A. Thalamus and hypothalamus B. Pituitary and adrenal glands C. Temporal and frontal lobes D. Pia mater and dura mater

A. Thalamus and hypothalamus

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? A. "I sleep on three pillows each night." B. "My feet are bigger than normal." C. "My pants don't fit around my waist." D. "I don't have the same appetite I used to."

A. "I sleep on three pillows each night."

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? A. Indwelling urinary catheter kit B. Tracheostomy set C. Cardiac monitor D. Humidifier

B. Tracheostomy set

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? A. Loose and wrinkled skin B. Ulcers and infection in the edematous area C. Evident scaring D. Cyanosis

B. Ulcers and infection in the edematous area

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina? A. Intractable B. Variant C. Unstable D. Refractory

C. Unstable

The nurse understands that for nursing to be considered a profession, many things need to be in place. Which element is not part of those considerations? A. Well-defined body of knowledge B. Strong service orientation C. Code of ethics D. Ongoing research E. Multidisciplinary approach

E. Multidisciplinary approach

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? A. Cerebral cortex B. Hypothalamus C. Medulla D. Midbrain

B. Hypothalamus

Which type of incontinence refers to the involuntary loss of urine due to extrinsic medical factors, particularly medications? A. Reflex B. Iatrogenic C. Overflow D. Urge

B. Iatrogenic

A client with metastatic brain cancer is admitted to the oncology floor. What action will the admitting nurse take regarding an advanced directive for this client? A. Decide on a treatment plan if the client cannot. B. Inform the client or legal guardian of the right to execute an advance directive. C. Respect the individuals' moral rights. D. Advise the client to refuse medical treatment if unable to make health care decisions.

B. Inform the client or legal guardian of the right to execute an advance directive.

A client comes to see the cardiologist for a routine follow-up visit. At the visit, the nurse reviews the client's electronic health record. The nurse is able to access a report from the client's last visit to the primary care provider last month and the report from an emergency department visit two weeks ago for reports of shortness of breath. The record also lists two changes in the client's medication based on the emergency department visit. The nurse's ability to access this information reflects which concept? A. Usability B. Interoperability C. Optimization D. Security

B. Interoperability

An informatics nurse specialist is attempting to identify a connection between a client's health history and the client's current health status. The nurse specialist interprets and analyzes the various items documented to determine the relationship. The nurse is integrating which component of the nursing informatics framework? A. Data B. Knowledge C. Information D. Wisdom

B. Knowledge

The nurse is updating the records of a 10-year-old girl who had her appendix removed. Which action could jeopardize the privacy of the child's medical records? A. Changing identification and passwords monthly. B. Letting another nurse use the nurse's log-in session. C. Closing files before stepping away from computer. D. Printing out confidential information for transmittal.

B. Letting another nurse use the nurse's log-in session.

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet? A. Low oxalate B. Low purine C. High protein D. High sodium

B. Low purine

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart? A. Dopamine B. Nitroprusside C. Epinephrine D. Methoxamine

B. Nitroprusside

During assessment of a client with systemic lupus erythematosus (SLE), the nurse hears a friction rub when the stethoscope is placed over the heart. Which complication of SLE will the nurse document in the medical records and report to the health care provider? A. Pleural effusion B. Pericarditis C. Pneumonia D. Vasculitis

B. Pericarditis

While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following? A. Positive Trousseau's sign B. Positive Chvostek's sign C. Hyperactive deep tendon reflex D. Tetany

B. Positive Chvostek's sign

Which medication system allows for client independence? A. Unit dose system B. Self-administered medication system C. Automated medication-dispensing system D. Bar Code Medication Administration (BCMA)

B. Self-administered medication system

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? A. Capillary refill of 2 seconds B. Shivering C. Cool, dry skin D. Urine output of 100 mL/hr

B. Shivering

The hospital nurse is providing discharge instructions to the caregivers of a 10-year-old child with a new prosthetic limb. Which finding will cause the nurse to contact the primary health care provider? A. The child was diagnosed with hypothyroidism as an infant. B. The child is being discharged home with the caregiver. C. The child's white blood cell (WBC) count is 9,000/mm3 (9 x 109/L). D. The child's blood pressure is 115/75 mm Hg.

B. The child is being discharged home with the caregiver.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A. The client's heart rate is rapid. B. The client's urinary output is 0.5 mL/kg/hour. C. The client's breathing is unlabored and skin is clammy. D. The client is conscious.

B. The client's urinary output is 0.5 mL/kg/hour.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? A. acupuncture B. an exercise routine that includes range-of-motion (ROM) exercises C. heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) D. cold therapy

B. an exercise routine that includes range-of-motion (ROM) exercises

When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported? A. chronic atrophic gastritis B. duodenal ulcer C. gastric cancer D. pernicious anemia

B. duodenal ulcer

An HIV-positive client discovers that their name is published in a report on HIV care prepared by the nurse. The client strongly opposes this and files a lawsuit against the nurse. Which offense has this nurse committed? A. unintentional tort B. invasion of privacy C. defamation D. negligence of duty

B. invasion of privacy

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to A. take a hot bath. B. rest in an air-conditioned room. C. increase the dose of muscle relaxants. D. avoid naps during the day.

B. rest in an air-conditioned room.

The nursing instructor who is teaching about disorders of the lower urinary tract realizes a need for further instruction when one of the students makes which statement? A. "Alterations in bladder function can include urinary obstruction with retention or stasis of urine." B. "Alterations in bladder function can include urinary incontinence with involuntary loss of urine." C. "Alterations in bladder function can only occur when there is incontinence." D. "Alterations in bladder function occurs frequently in the elderly."

C. "Alterations in bladder function can only occur when there is incontinence."

A nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates a good understanding of an advance directive? A. "An advance directive gives my family members permission to make decisions about my care needs." B. "An advance directive identifies the people I want to receive items from my estate once I pass away." C. "An advance directive allows my decisions for health care to be known if I cannot speak for myself." D. "An advance directive will allow my daughter to use my funds to pay for my health care costs if I cannot do so."

C. "An advance directive allows my decisions for health care to be known if I cannot speak for myself."

A client diagnosed with metastatic cancer is preparing for discharge. The physician orders morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use? A. "You must avoid driving or other activities that require alertness while taking controlled-release morphine sulfate." B. "Morphine sulfate is an opioid and you may develop a tolerance to it. This is an expected response and is not harmful." C. "Federal law prevents refills of this medication. Your physician will give you a new prescription when you need more medicine." D. "If you no longer require the morphine sulfate controlled-release tablets for your cancer pain, do not take any leftover pills for other disorders."

C. "Federal law prevents refills of this medication. Your physician will give you a new prescription when you need more medicine."

A client is learning how to perform Kegel exercises. Which statement by the client indicates a need for additional teaching? A. "I need to sit or stand with my legs slightly apart." B. "I should draw in my muscles like when I'm moving my bowels." C. "I need to hold the position for at least 15 seconds." D. "I should repeat the sequence of exercises 3 to 4 times a day."

C. "I need to hold the position for at least 15 seconds."

A pregnant woman reports she is interested in breastfeeding to promote improved health for her child. Which statement by the nurse is most appropriate? A. "Breastfeeding will improve your child's health." B. "Breastfeeding provides what is called active immunity." C. "Passive immunity can be transmitted to your child providing him with some temporary immunity against illness." D. "Lifelong immunity is provided against some bacterial illnesses from breasting."

C. "Passive immunity can be transmitted to your child providing him with some temporary immunity against illness."

The nurse instructs a client recovering from a myocardial infarction (MI) about cardiac rehabilitation. The client states, "I will not be able to do rehabilitation because I have very bad knees." What is the nurse's best response? A. "We can ensure you are prescribed pain control medications prior to discharge so you can participate." B. "There are other physical activities you can do at home that are also beneficial for your recovery." C. "The rehabilitation team will assess you and recommend activities that accommodate for your knee problems." D. "Before discharge, we will send in a consult to an orthopedic specialist to get your knee issue addressed."

C. "The rehabilitation team will assess you and recommend activities that accommodate for your knee problems."

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve? A. 1 to 2 B. 3 to 5 C. 6 to 12 D. 13 to 18

C. 6 to 12

The nurse is teaching a group of parents about eyes and eye concerns. The nurse tells these caregivers about a condition that occurs when unequal curvatures in the cornea bend the light rays in different directions and this causes images to be blurred. The condition the nurse is referring to is: A. Refraction B. Myopia C. Astigmatism D. Hyperopia

C. Astigmatism

What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? A. Come to the clinic for IV fluid therapy daily. B. Limit the fluid intake at night. C. Consume adequate amounts of fluid. D. Weigh daily.

C. Consume adequate amounts of fluid.

A parent brings a 15-year-old adolescent into the clinic, stating "I cannot wake him up in the morning. He has been late for school several times and I do not know what to do any longer." Which sleep syndrome is the nurse aware is common in adolescents? A. Free-running sleep disorder (FRSD) B. Irregular sleep-wake rhythm (ISWR) C. Delayed sleep phase syndrome (DSPS) D. Acute shifts in the sleep-wake cycle

C. Delayed sleep phase syndrome (DSPS)

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Despite various medication regimes, the client's symptoms are gradually increasing. The nurse realizes that this client is which phase of the Trajectory Model of Chronic Illness? A. Unstable B. Acute C. Downward D. Dying

C. Downward

The client is diagnosed with primary hypertension. The nurse is educating a client about dietary changes that help decrease blood pressure. Which menu selection indicates the need for further client education? A. Salad with a grilled chicken; unsweetened tea B. Baked fish, broccoli, and oranges C. Ham sandwich with mustard, carrots and cheesy dip D. Turkey sandwich on whole wheat with lettuce and tomato; sweetened tea

C. Ham sandwich with mustard, carrots and cheesy dip

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? A. Instruct the client to have low-residue meals. B. Allow the client to ingest fat-free meal. C. Permit the client to drink only clear liquids. D. Provide saline gargles to the client.

C. Permit the client to drink only clear liquids.

A nurse is caring for a client at the local healthcare facility. Which ensures that legislation related to client confidentiality is implemented at the facility? A. Ensure that the client's name is displayed on the first page of all faxed records. B. Put the client's health information up on a whiteboard to be seen by health care workers. C. Place in private areas light boxes for examining x-rays with the client's name. D. Do not present end-of-shift reports to the nurse coming on duty, in order to maintain privacy.

C. Place in private areas light boxes for examining x-rays with the client's name.

The nurse is interviewing the caregivers of a child admitted with a diagnosis of type 1 diabetes mellitus. The caregiver states, "She is hungry all the time and eats everything, but she is losing weight." The caregiver's statement indicates the child most likely has: A. Polyuria B. Pica C. Polyphagia D. Polydipsia

C. Polyphagia

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take? A. Print a copy of the medication record at the nurse's station to use at the bedside in order to administer the medications on time. B. Use the medication dispensing terminal to prepare the medications, and print a dispensing receipt to use for patient identification at the beside. C. Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. D. Wait for a mobile computer to become available, and explain to the instructor that the reason for late administration was related to adhering to safety policy.

C. Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one.

A nurse realizes she is 1 hour and 30 minutes late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next? A. No further action is necessary. B. The nurse should notify the physician of the error. C. The nurse should follow facility procedures for reporting an error. D. The nurse should document a medication error in the client's chart.

C. The nurse should follow facility procedures for reporting an error.

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion? A. Use should be limited to times when a client has demonstrated violence and has inflicted harm to self or others. B. Use should be limited to times when medications have been unsuccessful in de-escalating a situation. C. Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. D. Use should be limited to emergency situations in which the client is demonstrating a potential to be violent.

C. Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent.

The nurse walks into a room and finds the client forcefully expelling stomach contents into a wash basin. When documenting this occurrence, the nurse will use the term: A. Nauseous B. Retching C. Vomiting D. Expatriate

C. Vomiting

A child has been brought to an urgent care clinic. The parents state that the child is "not making water." When taking a history, the nurse learns the child had a sore throat about 1 week ago but seems to have gotten over it. "We [parents] only had to give antibiotics for 3 days for the throat to be better." The nurse should suspect the child has developed: A. acute renal failure. B. kidney stones. C. acute postinfectious glomerulonephritis. D. nephrotic syndrome.

C. acute postinfectious glomerulonephritis.

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine? A. serum potassium level B. lymphocyte count C. albumin level D. CBC differential

C. albumin level

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? A. pulse rate of 84 beats/minute B. respiration 26 breaths/minute C. blood pressure 84/52 mm Hg D. temperature of 100.2° F (37.9° C)

C. blood pressure 84/52 mm Hg

The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is: A. human immunodeficiency virus (HIV) positive. B. being treated for active tuberculosis (TB). C. diagnosed with mastitis. D. currently prescribed lithium.

C. diagnosed with mastitis.

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of: A. positive nitrogen balance. B. anabolism. C. negative nitrogen balance. D. digestion.

C. negative nitrogen balance.

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client? A. ear B. mouth C. rectum D. axilla

C. rectum

The nurse has been caring for a child who has been receiving growth hormone therapy for several years. When the child returns for evaluation following a sudden growth spurt, what nursing diagnosis should the nurse most likely add to the plan of care? A. disturbed body image related to change in height B. deficient knowledge regarding drug therapy C. risk for imbalanced nutrition: less than body requirements related to metabolic changes D. decreased cardiac output related to increased metabolic needs

C. risk for imbalanced nutrition: less than body requirements related to metabolic changes

A 4-year-old child with a urinary tract infection is scheduled to have a voiding cystourethrogram. When preparing the child for this procedure, the nurse would want to prepare the child to: A. have a local anesthetic injected prior to the procedure. B. drink three glasses of water during the procedure. C. void during the procedure. D. anticipate a headache afterward.

C. void during the procedure.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement? A. "Late preterm infant complications are considered minor compared to the preterm newborn." B. "The late preterm infant is more mature and able to cope as well as a full-term infant." C. "Late preterm newborns have fewer clinical problems leading to shorter hospital stays." D. "A late preterm newborn may have more clinical problems compared with full-term newborns."

D. "A late preterm newborn may have more clinical problems compared with full-term newborns."

The parents of a 10-year-old girl voice concern to the nurse because their daughter seems to "have a higher amount of body fat" than they expect based on the healthy eating habits and high activity level of the family. What is the best response by the nurse? A. "Do you think maybe your daughter eats in the evening or when you are monitoring her intake at home? You may want to ask her." B. "Girls are always heavier than boys it seems. I'm sure she just falls into that category." C. "Her metabolism may be slower than the rest of your family. Try increasing her activity to see if her body fat decreases." D. "Before adolescence the body fat composition of school-age children increases earlier and in greater amounts in girls than in boys."

D. "Before adolescence the body fat composition of school-age children increases earlier and in greater amounts in girls than in boys."

The nurse includes information regarding methods to enhance sleep for a client who experiences insomnia due to posttraumatic stress disorder (PTSD). Which client statement indicates a need for additional teaching regarding sleep hygiene? A. "I will avoid taking naps during the day." B. "I will maintain the same sleep schedule 7 days a week." C. "I will avoid caffeinated beverages during the late afternoon and early evening hours." D. "I have found that drinking a glass or two of wine every night helps me to fall asleep."

D. "I have found that drinking a glass or two of wine every night helps me to fall asleep."

A client has undergone a kidney transplant and voices concerns about organ rejection to the nurse. The most appropriate response by the nurse would be: A. "Kidney transplantation is 100% successful, and there is no need for you to worry." B. "Your new kidney will continue to work fine as long as you do not drink any alcohol." C. "There is no need to worry about rejection because the occurrence of rejection is low with kidney transplant." D. "You will be given medication to decrease the likelihood of your immune system attacking your new kidney."

D. "You will be given medication to decrease the likelihood of your immune system attacking your new kidney."

During a humanitarian trip to an underdeveloped country, a medical student is assessing a 6-year-old male who has a protuberant abdomen, dry hair, and wrinkled skin. The child's heart rate is 59 beats per minute, blood pressure 89/50 and temperature 95.2°F (35.1°C). What is the most likely etiology of the child's health problems? A. A diet lacking in fat-soluble vitamins. B. Fluid and electrolyte imbalances secondary to low carbohydrate intake. C. A diet that is low in high in carbohydrates but low in fat. D. A diet deficient in both protein and calories.

D. A diet deficient in both protein and calories.

The health care provider prescribes cold therapy every 4 hours for a client after foot surgery. The nurse places the ice pack directly on the client's skin and returns 60 minutes later. After removal of the ice pack, the skin is pale and cold to the touch. The client develops frostbite and begins a lawsuit for malpractice. When reviewing the case, the nurse attorney recognizes which most important statement about the malpractice suit? A. The client has a responsibility to report loss of sensation to prevent frostbite. B. The standard of care was established, so the nurse will not be held liable. C. The client will have difficulty finding causation. D. All elements are in place to hold the nurse liable.

D. All elements are in place to hold the nurse liable.

The nurse is reviewing a health care provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action? A. Fix the abbreviations in the EHR. B. Confirm the abbreviations with another nurse. C. Administer medications as ordered. D. Contact the health care provider to clarify the orders.

D. Contact the health care provider to clarify the orders.

A client was found unconscious on the bathroom floor with self-inflicted wrist lacerations. An ambulance was called and the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Which nursing intervention is most appropriate? A. Observe for extrapyramidal symptoms. B. Begin a therapeutic relationship. C. Explore precipitating factors for the suicide attempt. D. Continue suicide precautions.

D. Continue suicide precautions.

A client has been receiving chemotherapy for cancer treatment. The client is competent and has been actively involved in decisions regarding care; however, the client has now decided to refuse treatment. What should the nurse do when the client refuses the next dose of chemotherapy? A. Persuade the client to take the medication as ordered. B. Ensure that the client understands the rationale for taking the medication. C. Ask the client's spouse to encourage the client to take the chemotherapy. D. Document the client's choice and offer to discuss feelings about the chemotherapy.

D. Document the client's choice and offer to discuss feelings about the chemotherapy.

A nurse is explaining medication benefits and adverse effects to a client with a history of psychosis. The client's sibling states that explaining things to the client is a waste of the nurse's time. What information about informed consent should the nurse use to respond to the sibling's negative statement? A. Informed consent doesn't apply to clients who experience psychosis. B. The nurse may assume that the client understands at least some of the information. C. A third party must be present when a nurse informs clients about treatment options. D. Informed consent is an important part of effective client care that helps accomplish treatment goals.

D. Informed consent is an important part of effective client care that helps accomplish treatment goals.

Which intervention is the most critical for a client with myxedema coma? A. Administering an oral dose of levothyroxine (Synthroid) B. Warming the client with a warming blanket C. Measuring and recording accurate intake and output D. Maintaining a patent airway

D. Maintaining a patent airway

Peptic ulcer disease occurs more frequently in people with which blood type? A. A B. B C. AB D. O

D. O

When a person authorizes another to make medical decisions on his or her behalf, the person has written which of the following? A. Treatment directive B. Living will C. Standard addendum to a will D. Proxy directive

D. Proxy directive

A nurse witnesses a peer tell a client, "You are a mother now and you have to do what is best for you baby. You have to breastfeed her!" Which is the best action by the nurse? A. Approach the client later and provide correct information. B. Immediately interrupt the conversation and reprimand the nurse. C. Fill out an incident report to go in the nurse's personnel file. D. Pull the nurse aside and inquire as to the content of the conversation.

D. Pull the nurse aside and inquire as to the content of the conversation.

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease? A. Telangiectasia B. Ecchymosis C. Fluid-filled vesicles D. Purplish cutaneous lesions

D. Purplish cutaneous lesions

A nurse is monitoring a client closely for malignant hyperthermia because the client received which NMJ blocker? A. Pancuronium B. Vecuronium C. Atracurium D. Succinylcholine

D. Succinylcholine

A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage? A. Stool continuously oozes from it. B. Absorption of nutrients is diminished. C. Peristalsis is greatly decreased. D. Urine drains from it continuously.

D. Urine drains from it continuously.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? A. Blood urea nitrogen (BUN) level of 22 mg/dl B. Serum creatinine level of 1.2 mg/dl C. Temperature of 100.2° F (37.8° C) D. Urine output of 250 ml/24 hours

D. Urine output of 250 ml/24 hours

An adolescent reports a small (0.2 cm), round, serous-filled spot at the corner of the mouth. How should the nurse document this finding? A. Cyst B. Ulceration C. Fissure D. Vesicle

D. Vesicle

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? A. After completing a wound dressing B. Before direct contact with clients C. After direct contact with clients D. When hands are visibly soiled

D. When hands are visibly soiled

The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client? A. assessing blood pressure and heart rate frequently B. identifying a code-level status C. maintaining intravenous fluids D. alerting the healthcare provider of the third-degree heart block

D. alerting the healthcare provider of the third-degree heart block

A student is choosing an educational path and desires a nursing degree with a track for community nursing and leadership and that allows for classes in liberal arts. The student would best be suited in which type of program? A. licensed practical nursing program B. certification in a nursing specialty C. diploma nursing program D. baccalaureate program

D. baccalaureate program

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to A. increase metabolic rate. B. increase glucose demands. C. increase skeletal muscle breakdown. D. decrease catabolism.

D. decrease catabolism.

A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for A. exophthalmos and conjunctival redness. B. flushed, warm, moist skin. C. systolic murmur at the left sternal border. D. decreased body temperature and cold intolerance.

D. decreased body temperature and cold intolerance.

What is Sim's position?

Patient lies on their left side, with right hip and knee bent. The lower arm is behind the back, the thigh flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the left arm is resting behind the body.

The nurse is bathing a client and discovers a pressure ulcer on the buttocks. Which nursing intervention, following completion of the bath, is completed first? Position the client off of the ulcer. Massage the ulcerated area vigorously. Place antibiotic cream over the ulcerated area. Notify the health care provider and await orders.

Position the client off of the ulcer.

Parents bring their daughter to the health care facility for evaluation. They report that lately the child seems rather pale and really tired. What would the nurse most likely find with further assessment if the child has acute lymphoblastic leukemia (ALL)? Select all that apply. 1. Bleeding from the oral mucous membranes 2. Headache 3. Painless cervical lymphadenopathy 4. Chest pain 5. Low-grade fever

1. Bleeding from the oral mucous membranes 2. Headache 3. Painless cervical lymphadenopathy 5. Low-grade fever

A nurse is teaching a class on holistic nutritional therapy to a group of young and middle-aged adults in the community. The nurse creates a menu of food and beverage choices and asks the group the select the best choices. The nurse determines that the teaching was successful when the group chooses which food? Select all that apply. 1. Fresh corn on the cob in season 2. Frozen packaged french fries 3. Organically grown chicken 4. Bottled spring water 5. Canned stewed tomatoes

1. Fresh corn on the cob in season 3. Organically grown chicken 4. Bottled spring water

A nurse is conducting a teaching session on sudden infant death syndrome (SIDS) for expectant parents. Which information should the nurse include? Select all that apply. 1. Sharing a room allows for monitoring of the infant. 2. Co-bedding or sharing a bed creates parental bonding. 3. Place the infant on his or her back to sleep. 4. Maintain neutral temperatures and avoid overheating. 5. Allow the infant to sleep with a bottle.

1. Sharing a room allows for monitoring of the infant. 3. Place the infant on his or her back to sleep. 4. Maintain neutral temperatures and avoid overheating.

A competent client requiring long-term mechanical ventilation privately tells a nurse that they want the ventilator withdrawn. Which response by the nurse is best? A. "Tell me more about how you are feeling." B. "Now that I'm here, tell me all about it." C. "How does your family feel about this?" D. "I'll let your healthcare provider know your feelings."

A. "Tell me more about how you are feeling."

The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of: A. Ewing sarcoma. B. Hodgkin disease. C. non-Hodgkin lymphoma. D. neuroblastoma.

A. Ewing sarcoma.

During an eye assessment the nurse notes inflammation of the client's cornea. The nurse should document this as which condition? A. Keratitis B. Arcus senilis C. Uveitis D. Conjunctivitis

A. Keratitis

The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing? A. Moro B. Babinski C. palmar grasp D. root

A. Moro

The occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial? A. principles of body alignment B. the use of protective clothing C. the use of ear plugs D. appropriate storage of combustible cleaning solutions

A. principles of body alignment

A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what? A. Aphasia B. Agnosia C. Apraxia D. Disturbance of executive function

B. Agnosia

The nurse is caring for a client who is HIV positive. What laboratory test is used to determine this client's ability to fight against viral infections? A. BUN B. CD4 C. AST D. RBCs

B. CD4

A client has bipolar disorder and has just begun a regimen of lithium, 600 mg tid. Which is the most critical management issue for the client during the first 2 weeks of treatment? A. Ascertaining that the client is taking a full dose daily B. Ensuring the client's blood levels reach a therapeutic and safe dose C. Educating the client about the side effects of lithium D. Monitoring the client's cardiac status

B. Ensuring the client's blood levels reach a therapeutic and safe dose

The nurse recognizes which condition as an integumentary manifestation of chronic renal failure? A. Asterixis B. Gray-bronze skin color C. Tremors D. Seizures

B. Gray-bronze skin color

Which zone of the surgical area only requires attire in the form of scrub clothes and caps? A. Unrestricted zone B. Semi-restricted zone C. Restricted zone D. Operative zone

B. Semi-restricted zone

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful? A. All pain is the same. B. The characteristics of labor pain follow a pattern. C. Women innately know how to deal with labor pain. D. If the woman is in too much pain, a cesarean birth is an option.

B. The characteristics of labor pain follow a pattern.

Which type of ventilator has a preset volume of air to be delivered with each inspiration? A. Negative pressure B. Volume cycled C. Time cycled D. Pressure cycled

B. Volume cycled

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? A. "I was sitting at home watching television." B. "I was putting my shoes on." C. "I was brushing my teeth." D. "I was taking a bath."

C. "I was brushing my teeth."

A new client on hemodialysis is watching his blood being filtered through a dialyzer. He asks the nurse how much blood typically passes through the kidney every minute? The nurse responds: A. 100-300 mL/minute. B. 500-800 mL/minute. C. 1000-1300 mL/minute. D. 1700-2000 mL/minute.

C. 1000-1300 mL/minute.

Which is a sympathetic effect of the nervous system? A. Decreased blood pressure B. Increased peristalsis C. Dilated pupils D. Decreased respiratory rate

C. Dilated pupils

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize? A. Place another blanket on the infant. B. Check the infant's vital signs. C. Move the infant away from the window. D. Observe infant's status.

C. Move the infant away from the window.

The nurse is planning community education on the prevalence and incidence of disabilities in the United States. The nurse includes that, according to the U.S. Census (2010), what percentage of people are diagnosed with a disability? A. 5 B. 10 C. 14 D. 20

D. 20

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A. A full liquid diet B. Isotonic enteral nutrition every 6 hours C. An infusion of crystalloids at an increased rate of flow D. A continuous infusion of total parenteral nutrition

D. A continuous infusion of total parenteral nutrition

A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply. 1. "I am not able to provide that information." 2. "Client privacy is part of the hospital code of conduct." 3. "You should know better than to ask that question." 4. "You will need to ask your manager." 5. "The client is in room 313."

1. "I am not able to provide that information." 2. "Client privacy is part of the hospital code of conduct."

Vestibular suppressants used in the treatment of vertigo originate from which of the following drug classifications? Select all that apply. 1. Anticholinergics 2. Antihistamines 3. Benzodiazepines 4. Cholinergics 5. Aminoglycosides

1. Anticholinergics 2. Antihistamines 3. Benzodiazepines

The nurse is developing a plan of care for a 65-year-old client who has significant hearing loss. The nurse will include which suggestions that can assist this older adult with hearing loss? Select all that apply. 1. Being evaluated for hearing aids/devices 2. Investigating TV stations with closed captioning available 3. Hiring round-the-clock home health care 4. Using ear drops daily to keep ears clean and free of bacteria 5. Flashing alarms instead of high-frequency warning sounds

1. Being evaluated for hearing aids/devices 2. Investigating TV stations with closed captioning available 5. Flashing alarms instead of high-frequency warning sounds

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. What are her following steps to complete this insertion of the catheter.

1. Clean each labial fold, then the area directly over the meatus. 2. Insert the lubricated catheter into the urethra. 3. Advance the catheter until there is a return of urine. 4. Inflate the balloon with the correct amount of sterile saline. 5. Discard used supplies.

A nurse is providing care to a neonate. Put steps in the order that the nurse would implement to properly perform ophthalmia neonatorum prophylaxis.

1. Wash hands and put on gloves. 2. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive treatment. 3. Gently raise the neonate's upper eyelid with the index finger and gently pull the lower eyelid down with the thumb. 4. Instill the ointment in the lower conjunctival sac 5. Close and manipulate the eyelid to spread the medication over the eye 6. Repeat the procedure for the other eye.

A child is diagnosed with a latex allergy. When developing the teaching plan for this child, the nurse would include what foods to avoid? Select all that apply. 1. pineapples 2. cherries 3. bananas 4. cheese 5. peanut butter 6. squash

1. pineapples 2. cherries 3. bananas

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. 1. Give newborns water and other foods to balance nutritional needs. 2. Help the mother initiate breastfeeding within 30 minutes of birth. 3. Encourage breastfeeding of the newborn infant on demand. 4. Provide breastfeeding newborns with pacifiers. 5. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.

2. Help the mother initiate breastfeeding within 30 minutes of birth. 3. Encourage breastfeeding of the newborn infant on demand. 5. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. 1. The nurse was correct to call a code blue. 2. The physician was correct to stop resuscitation efforts. 3. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. 4. The nurse must have read the chart incorrectly. 5. The code should have continued.

2. The physician was correct to stop resuscitation efforts. 3. By calling a code blue, the nurse disregarded the client's advance directives and DNR order.

A client is refusing to take the prescribed oral medication. Which measure by the nurse can be used to get the client to take the medication? Select all that apply. 1. crushing the medication and hiding it in apple sauce 2. suggesting a liquid form of the medication instead of a pill 3. asking the client the reason for not taking the medication 4. explaining the purpose of the medication to the client 5. having a family member give the medication

2. suggesting a liquid form of the medication instead of a pill 3. asking the client the reason for not taking the medication 4. explaining the purpose of the medication to the client

Which statements made by the nurse indicate how insulin pens simplify self-administered insulin for clients? Select all that apply. 1. "The plastic cylinders of insulin pens are softer." 2. "Insulin pens are less expensive than insulin vials." 3. "The cylinder of the insulin pen contains a prefilled reservoir of insulin." 4. "The dose of insulin in an insulin pen is displayed in a window of the syringe." 5. "The insulin pen automatically resets the dose window to zero, following the injection."

3. "The cylinder of the insulin pen contains a prefilled reservoir of insulin." 4. "The dose of insulin in an insulin pen is displayed in a window of the syringe." 5. "The insulin pen automatically resets the dose window to zero, following the injection."

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? A. "Legal policy requires nursing practice to be permanently integrated into the client record." B. "It would be easier to do it that way. You could develop a tool to use." C. "The facility requires us to document client care this way because of the computer application used." D. "The electronic health record we use does not allow us to use different formats."

A. "Legal policy requires nursing practice to be permanently integrated into the client record."

The unlicensed assistive personnel reports to the nurse that the client is refusing to eat the food on the meal tray. The nurse observes the client eating the food brought in by family members. How should the nurse respond? A. "What type of food did your family prepare for you, and does it have special meaning?" B. "You can only eat the food that we serve you." C. "Do you understand that you are on a strict diet and any variation can cause you harm?" D. "I will need to get permission from your health care provider for you to eat the food your family brought in."

A. "What type of food did your family prepare for you, and does it have special meaning?"

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? A. "You must consume a diet rich in protein, such as chicken, fish, and beans." B. "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." C. "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." D. "You must consume a diet low in fat by limiting dairy products and concentrated sweets."

A. "You must consume a diet rich in protein, such as chicken, fish, and beans."

What is the duration of regular insulin? A. 4 to 6 hours B. 3 to 5 hours C. 12 to 16 hours D. 24 hours

A. 4 to 6 hours

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? A. 500 additional calories per day B. 1,000 additional calories per day C. 250 additional calories per day D. 750 additional calories per day

A. 500 additional calories per day

A nursing student is preparing for a debate with another student about e-mental health. Which would the nurse include to support its use? A. Ability to provide services in a variety of locations B. Improvement in therapeutic relationship C. Ensured quality of care D. Ability to provide high-intensive services for many mental illnesses

A. Ability to provide services in a variety of locations

A parent has sought care from the nurse practitioner to treat a child's fever. The nurse practitioner is most likely to recommend what nonsalicylate drug? A. Acetaminophen B. Ibuprofen C. Naproxen D. Indomethacin

A. Acetaminophen

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? A. Administer an analgesic as ordered. B. Massage the extremities. C. Elevate the legs. D. Apply a heat lamp.

A. Administer an analgesic as ordered.

The perioperative nurse is caring for a client who is undergoing abdominal surgery with the inclusion of succinylcholine in the client's anesthesia. The anesthesiologist tells the team that the client is exhibiting signs and symptoms suggestive of malignant hyperthermia. What is the nurse's best action? A. Anticipate IV administration of dantrolene B. Initiate resuscitation C. Prepare to administer acetylcysteine IV D. Administer naloxone IV as per facility protocol

A. Anticipate IV administration of dantrolene

A 17-year-old female has announced to her family physician a desire to wholly eliminate fats from her diet. Which aspect of the role of fats would underlie the physician's response to the client? A. Apart from providing energy, fats are necessary as carriers of certain vitamins and are precursors to prostaglandins. B. An extreme low-fat diet is associated with an increase in undesirable HDL cholesterol. C. Fats are a key source of dietary nitrogen and their elimination from the diet is associated with a negative nitrogen balance. D. The total elimination of fat from the diet is associated with the development of ketosis.

A. Apart from providing energy, fats are necessary as carriers of certain vitamins and are precursors to prostaglandins.

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? A. Apply warm or cool cloths to the forehead or back of the neck B. Maintain hydration by drinking eight glasses of fluid a day C. Perform the Heimlich maneuver D. Use pressure-relieving pads or a similar type of mattress

A. Apply warm or cool cloths to the forehead or back of the neck

A nurse is attempting to reduce pain that a child is experiencing after an emergency appendectomy. What intervention can the nurse provide to meet this goal? A. Assess the child frequently and use pharmacologic and nonpharmacologic methods of pain relief as needed. B. Have the child turn every 2 hours prior to administering pain medication. C. Encourage oral fluids after surgery. D. Provide diversional activities postoperatively so the child will not focus on the pain.

A. Assess the child frequently and use pharmacologic and nonpharmacologic methods of pain relief as needed.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature? A. Assure the newborn has a cap on the head and is kept covered. B. Maintain accurate intake and output and monitor for dehydration. C. Educate the parents to rinse the newborn skin well after using soap. D. Monitor the newborn's skin for changes related to fluid loss, such as turgor.

A. Assure the newborn has a cap on the head and is kept covered.

At which of the following spinal cord injury levels does the patient have full head and neck control? A. C5 B. C4 C. C3 D. C2

A. C5

The nurse is planning to collect a 24-hour urine sample for hormone assay. In which situation does the nurse collaborate with the health care provider to find an alternate type of testing? A. Client has anuria. B. Client has anemia. C. Client has diabetes. D. Client has hypothyroidism.

A. Client has anuria.

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning? A. Cognitive B. Affective C. Psychomotor D. Interpersonal

A. Cognitive

A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? A. Control the shivering. B. Place the client on a warming blanket. C. Keep the client dry and covered. D. Maintain the client in a supine position with legs elevated 12 inches.

A. Control the shivering.

The nurse is preparing hospital discharge instructions for a 7-year-old girl recovering from head trauma and receiving gastrostomy feedings. Which activity is most important before the child is discharged home? A. Determining the parents' ability to administer the enteral feedings. B. Assessing the parents' emotional status. C. Helping the family to access financial resources. D. Preparing a list of home equipment and supplies needed.

A. Determining the parents' ability to administer the enteral feedings.

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmia. Which of the following assessment considerations is essential when caring for this client? A. Digoxin level B. Cardiac output C. Activity level D. Dyspnea

A. Digoxin level

The provider is testing the client's ability to identify the specific location of skin touch in two different areas. This ability is communicated through which pathway? A. Discriminative B. Anterior spinothalamic C. Lateral spinothalamic D. Paleospinothalamic

A. Discriminative

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse? A. Florence Nightingale B. Dorothea Orem C. Hildegard Peplau D. Virginia Henderson

A. Florence Nightingale

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency? A. Health teaching and health promotion B. Consultation C. Quality of practice D. Leadership

A. Health teaching and health promotion

Which statement is not true regarding a medication administration record (MAR)? A. If the client declines the dose, the nurse does not have to document this on the MAR. B. The MAR distinguishes between routine and "as needed" medications. B. The MAR identifies routine times for medication administration. C. After using an electronic MAR, the nurse should log off.

A. If the client declines the dose, the nurse does not have to document this on the MAR.

A client is reporting cracking fissures in the corner of her mouth. Which instruction should the nurse include in the information provided to the client? A. Increase intake of eggs and milk. B. Avoid vegetables for the next few weeks. C. Nuts and legume intake should be increased. D. Potatoes and other starch containing foods should be restricted.

A. Increase intake of eggs and milk.

A client who was diagnosed with iron deficiency anemia is worried because she does not know why she was prescribed iron supplements. The nurse teaches the client about which action of oral iron administration? A. Iron acts by elevating the serum iron concentration to replenish hemoglobin to treat anemia. B. Iron supplements prevent depletion of hemoglobin cells from anxiety to treat anemia. C. Iron supplements prevent infection so hemoglobin cells grow back faster to treat anemia. D. Iron supplements prevent bleeding to replenish hemoglobin cells faster to treat anemia.

A. Iron acts by elevating the serum iron concentration to replenish hemoglobin to treat anemia.

A child is brought to the clinic with fever, cough, and coryza. The nurse inspects the child's mouth and observes what look like tiny grains of white sand with red rings. How would the nurse document these findings? A. Koplik spots B. Lymphadenopathy C. Slapped cheek appearance D. Nits

A. Koplik spots

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what? A. Nonmaleficence B. Informed consent C. Self-determination D. Pro-choice

A. Nonmaleficence

A client diagnosed with Goodpasture syndrome would require which therapy to remove proteins and autoantibodies from the system? A. Plasmapheresis B. Kidney removal C. Renal transplant D. Intravenous calcium

A. Plasmapheresis

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? A. Respect the client's and family members' choices. B. Share emotional pain. C. Abide by the dying client's wishes. D. Ask the family members about spiritual care.

A. Respect the client's and family members' choices.

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first? A. Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. B. Check the second client's identification and administer the remaining medication to him. C. Alert the charge nurse that they made a medication error. D. Document the medication error and completion of the variance report in the client's chart and notify the physician.

A. Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed.

The nurse is caring for a 6-month-old infant diagnosed with otitis media. Which clinical manifestation would likely have been noted in this child? A. Shaking the head and pulling the ear B. Severe vomiting and confusion C. High-pitched cry and nuchal rigidity D. Body stiffening and loss of consciousness

A. Shaking the head and pulling the ear

The nurse is caring for a client on a telemetry unit following a myocardial infarction. The client has undergone numerous medication changes since the event. Which food should be avoided when a client is taking warfarin sodium following a myocardial infarction? A. Spinach B. Milk C. Orange juice D. Wheat bread

A. Spinach

A nurse enters a client's room to administer medications and finds the client resting in bed with eyes closed. The nurse checks the client's name bracelet and calls the client by name. The client arouses easily and states, "I must have dozed off." Which stage of sleep does the nurse recognize this client was in? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

A. Stage 1

The nurse is assessing an older adult client who has suffered injury to the nervous system. The client reports pain on a scale of 8 out of 10. What additional information does the nurse need to develop a plan to provide care to decrease the pain? A. The client's psychosocial views of taking pain medications. B. How long the client has had chronic pain. C. If the client lives alone or has a pet. D. Nothing else, the nurse has all the information.

A. The client's psychosocial views of taking pain medications.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse? A. The new nurse places the client in the left lateral recumbent position. B. The new nurse changes gloves before preparing the feeding bag. C. The new nurse interrupts the feeding every 4 hours and aspirates gastric contents. D. The new nurse asks the client whether nausea or abdominal pain is present.

A. The new nurse places the client in the left lateral recumbent position.

A client tells the nurse that he is experiencing involuntary loss of urine associated with a strong desire to void (urgency). The nurse would recognize this as: A. Urge incontinence B. Stress incontinence C. Overflow incontinence D. Transient incontinence

A. Urge incontinence

A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for: A. Ventricular dysrhythmia B. Postoperative anxiety C. Increased intercranial pressure D. Postoperative migraine

A. Ventricular dysrhythmia

The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication? A. With food B. 2 hours before meals C. 2 hours after meals D. At bedtime with 8 ounces of fluid

A. With food

A nurse is assigned to care for a client with an acute exacerbation of chronic obstructive pulmonary disease. During the shift, the nurse discovers that the client lives alone and holds a full-time job. Which type of disability would the nurse state the client has? A. acquired B. developmental C. age-related D. acute nontraumatic

A. acquired

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? A. care-based ethics B. deontology C. utilitarianism D. principle-based ethics

A. care-based ethics

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be: A. client will participate in self-care measures by the end of the week. B. client will recognize the need for self-care. C. client will verbalize the need to use to use the bedpan by the end of shift. D. client will consent to no hygiene measures.

A. client will participate in self-care measures by the end of the week

A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? A. encouraging the client to push when they have a strong desire to do so B. alleviating perineal discomfort with the application of ice packs C. palpating the client's fundus for position and firmness D. completing the identification process of the newborn with the pregnant parent

A. encouraging the client to push when they have a strong desire to do so

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? A. lack of subcutaneous fat B. continual kicking C. continual crying D. constriction of blood vessels

A. lack of subcutaneous fat

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal? A. narrative notes B. SOAP notes C. focus charting D. charting by exception

A. narrative notes

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for an SGA infant? A. placental factors B. blood group incompatibility C. grand multiparity D. age of 30 years

A. placental factors

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? A. removing the initial dressing for incision inspection B. monitoring pain status and providing necessary relief C. supporting self-esteem concerns about the birth D. assisting with parent-neonate bonding

A. removing the initial dressing for incision inspection

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should A. stay with the client and encourage them to eat. B. help the client fill out their menu. C. give the client privacy during meals. D. fill out the menu for the client.

A. stay with the client and encourage them to eat.

While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate? A. "What makes you think that you might be dying?" B. "Tell me some more about what is on your mind." C. "You're just having a bit of a set-back. You'll be fine." D. "What has your physician told you about your condition?"

B. "Tell me some more about what is on your mind."

The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle collision. The child's body temperature fluctuates markedly, and the parents question why this is occurring. How should the nurse respond? A. "The child has developed a respiratory infection and needs antibiotics." B. "The child's sympathetic nervous system was damaged in the accident." C. "Urinary tract infections are common in children with spinal cord injuries." D. "It's hard to obtain accurate temperatures in children with spinal cord injuries."

B. "The child's sympathetic nervous system was damaged in the accident."

The nurse is caring for a couple in the transition period of labor. The client's partner asks about helping with the client's comfort at this time. What is the nurse's best response? A. "There's nothing that you can do to help right now." B. "You can stay close and help her focus on her breathing." C. "Please hold her leg back while she pushes." D. "You can go to the cafeteria to get her something to eat."

B. "You can stay close and help her focus on her breathing."

A client who suffers from spastic bladder has been catheterized to promote bladder emptying. Which medication should the nurse plan on the physician ordering to also treat this problem? A. Skeletal muscle relaxant B. Anticholinergic medication C. Calcium channel blocker D. Cholinergic

B. Anticholinergic medication

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? A. Prepare for a prostate examination. B. Ask the client to empty the bladder. C. Assist the client to a Fowler's position. D. Dim the lights for privacy.

B. Ask the client to empty the bladder.

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response? A. Reassure the parent that each infant's sleep needs are individual. B. Ask the parent for more information about the infant's sleep patterns. C. Instruct the parent to decrease the infant's daytime sleep to increase nighttime sleep. D. Inform the parent that the infant's growth and development are age-appropriate, so sleep isn't a concern.

B. Ask the parent for more information about the infant's sleep patterns.

A hospitalized client reports having difficulty resting. Which intervention would help promote rest? A. Leaving the client's door open so the client can see into the hallway B. Assisting the client with deep-breathing exercises C. Offering the client a cup of coffee D. Encouraging the client to take prescribed sedatives daily

B. Assisting the client with deep-breathing exercises

When caring for a client in the medical clinic who has tried to lose weight multiple times, the client asks the nurse if she should try a high-protein, very low-calorie restricted diet. The nurse encourages her to seek guidance from the health care provider as these diets may cause which complication? A. Hypothyroidism B. Cardiac dysrhythmias C. Pulmonary embolism D. Spontaneous fractures

B. Cardiac dysrhythmias

An informatics nurse specialist is working as part of a team that will be developing and implementing a new client assessment tool. During which phase of the system development lifecycle would the team be integrating information about workflow patterns, standard terminology, and recommendations for screen layout from supportive research? A. Analyze and plan B. Design and build C. Test D. Train

B. Design and build

The nurse collects a urine sample but forgets the sample in the client's room for several hours. What is the nurse's best action? A. Place the sample in the fridge immediately. B. Discard the sample and recollect in the morning. C. Label with the time collected and send immediately. D. Contact the laboratory to ask for guidance.

B. Discard the sample and recollect in the morning.

Which cerebral lobe contains the auditory receptive areas? A. Frontal B. Parietal C. Occipital D. Temporal

D. Temporal

Which is a focus of medical research rather than nursing research? A. Drug metabolism B. Health appraisal C. Prevention of trauma D. Promotion of recovery

A. Drug metabolism

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply. 1. Improvement in health care quality 2. Increased health disparities 3. Greater client engagement 4. Reduction in privacy breaches of client information 5. Reduced health of populations

1. Improvement in health care quality 3. Greater client engagement 4. Reduction in privacy breaches of client information

A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which bodily function aids heat conservation by reducing surface area for heat loss? A. Erection of pilomotor muscles B. Shivering C. Chattering D. Sweating

A. Erection of pilomotor muscles

The nurse is helping a client who experiences frequent constipation select meal choices for the day. Which food should the nurse encourage the client to order? A. Bananas B. Applesauce C. Bran cereal D. Pop-Tart

C. Bran cereal

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? A. hearing B. vision C. genetic-linked D. skeletal malformations

A. hearing

Which are true of nonprescription drugs? (Select all that apply.) 1. They require a prescription to obtain. 2. They are referred to as over-the-counter drugs. 3. They can be taken without risk to the client. 4. They have certain labeling requirements. 5. They should be taken only as directed on the label.

2. They are referred to as over-the-counter drugs. 4. They have certain labeling requirements. 5. They should be taken only as directed on the label

During the change of shift report, the nurse reports concerns about the parents of a hospitalized child understanding the written literature provided concerning the child's plan of treatment. Which observations would provide support to this concern? Select all that apply. 1. The child's mother asks many questions. 2. The child's mother asks for additional resources to review about the planned treatment. 3. The child's mother provides little responses to information provided. 4. The child's medical record contains information indicating the family frequently misses appointments. 5. The child's mother asks the nurse to complete paperwork for her.

3. The child's mother provides little responses to information provided. 4. The child's medical record contains information indicating the family frequently misses appointments. 5. The child's mother asks the nurse to complete paperwork for her.

A client arrives with a shoulder dislocation related to sword fighting practice. Which nursing educational topic is most accurate regarding this injury? A. "Dislocations become recurrent. They recur with the same motion but require less and less force each time." B. "If you go to physical therapy as prescribed, you will not likely experience this problem again." C. "Your bones must be weak. You should increase consumption of calcium daily." D. "Let me demonstrate for you how you can put your shoulder back into place if it happens again."

A. "Dislocations become recurrent. They recur with the same motion but require less and less force each time."

During a recent visit to the clinic, a client tells the nurse, "I've been using my cell phone to track and record the foods that I eat so that I can better understand if I'm making healthy food choices." The nurse interprets the client's statement as reflecting which technology? A. mHealth B. Telemedicine C. Patient portal D. Pharmacogenomics

A. mHealth

A client diagnosed with human papillomavirus (HPV) asks the nurse if she will be at risk for developing cervical cancer. The nurse best responds by making which statement? A. "Cervical cancer is typically caused by the herpes simplex virus, not the human papillomavirus (HPV)." B. "Certain strains of the human papillomavirus (HPV) have been associated with causing cervical cancer." C. "If you get the human papillomavirus (HPV) vaccine you will no longer be at risk for developing cervical cancer." D. "You will likely contract cervical cancer so frequent screening testing will be very important."

B. "Certain strains of the human papillomavirus (HPV) have been associated with causing cervical cancer."

A nurse is educating a client on the technique for performing breast self-examination. Which instruction should the nurse include in the teaching plan with regard to the different degrees of pressure that need to be applied on the breast? A. light pressure midway into the tissue B. medium pressure around the areolar area C. medium pressure on the skin throughout D. hard pressure applied down to the ribs

D. hard pressure applied down to the ribs

A client with muscular dystrophy has lost complete control of his lower extremities. He has some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair? A. anti-tip device B. extended breaks C. headrest support D. wheelchair belt

D. wheelchair belt

A nurse saw a coworker steal drugs from a locked cabinet. The supervisor notices the missing drugs and has a good idea who is responsible for the theft. The supervisor asks if the nurse saw anything out of the ordinary. Which professional value reflects a nurse's duty to tell the truth? A. veracity B. autonomy C. beneficence D. nonmaleficence

A. veracity

A health care provider prescribes intravenous normal saline solution to be infused at a rate of 150 ml/hour for a client. How many liter(s) of solution will the client receive during an 8-hour shift? Record your answer using one decimal place (For example: 6.2).

1.2

Which are examples of a nurse appropriately protecting a client's privacy? Select all that apply. 1. During a bed bath, the nurse exposes the client's upper torso while washing the client's face. 2. With the client's permission, the nurse explains the client's diagnosis to the client's spouse. 3. The nurse questions the client about the client's social life even though it does not affect care planning. 4. The nurse moves the client from the emergency department waiting room to a private area to collect assessment data. 5. Because the facility is a teaching facility, the nurse allows a nursing student to photograph a client for a care plan.

2. With the client's permission, the nurse explains the client's diagnosis to the client's spouse. 4. The nurse moves the client from the emergency department waiting room to a private area to collect assessment data.

A 4-year-old child diagnosed with Wilms tumor is admitted for surgery. What information would be most important for the nurse to include in the child's preoperative plan of care? A. Avoiding further abdominal palpation B. Performing dressing changes to the affected area C. Administering analgesics for pain D. Preparing the child for amputation

A. Avoiding further abdominal palpation

Which behavior by the nurse is stereotyping? A. Avoiding older adult clients because their care is time consuming B. Openly ridiculing the practice of acupuncture C. Explaining to others that Western medicine is always superior D. Grouping care assignments to allow ample time to care for complex clients

A. Avoiding older adult clients because their care is time consuming

A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which action should the nurse perform to prevent gastric reflux? A. Help the client into a Fowler position. B. Check for drug allergies in the client's history. C. Add diluted medication to the syringe. D. Administer the medication over several minutes.

A. Help the client into a Fowler position.

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? A. meticulous handwashing B. use of clean gloves for invasive procedures C. unlimited visitation from family and friends D. fluid intake limitations

A. meticulous handwashing

The charge nurse has just completed an inservice with a group of nursing students. One nurse student asks, "Why do I have to know how to give medications in different ways. I thought the unlicensed assistive personnel (UAP) performs those skills?" What is best response by the charge nurse? A. "Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes." B. "As a registered nurse you will not have to perform skills like bathing and administering medications unless you want to." C. "You will be able to perform all the skills the health care provider allows you to perform when you become a nurse." D. "Perhaps it is important to think and decide if nursing is the profession for you. There are other roles in health care for you to consider besides becoming a nurse."

A. "Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes."

A client was diagnosed with chronic gouty arthritis 2 years ago. The client has been taking sulfinpyrazone, 200 mg P.O. b.i.d. as maintenance therapy. How soon after administration of this drug does onset of action occur? A. 30 minutes B. 60 minutes C. 90 minutes D. 2 hours

A. 30 minutes

Which scenario is an example of certification? A. A nurse who demonstrates advanced expertise in a content area of nursing through special testing B. A hospital that meets the standards of the Joint Commission C. An education program that meets the standards of the National League for Nursing D. A graduate of a nursing education program who passes the NCLEX-RN

A. A nurse who demonstrates advanced expertise in a content area of nursing through special testing

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder? A. AIDS B. DAF C. CVID D. SCID

A. AIDS

An infant is suspected of having a severe primary immunodeficiency disease. Which effect on the infant makes early detection a priority? A. Administering live attenuated virus vaccines can be fatal. B. The infant may have developmental delays. C. The infant may develop food allergies. D. The infant is at risk for cardiovascular disease.

A. Administering live attenuated virus vaccines can be fatal.

The nurse observes that a coworker is unable to understand that an intelligent person would engage the services of a medicine man. The nurse's coworker has strong ethnocentric tendencies and an inability to recognize others' values, beliefs, and practices. The nurse understands that the coworker's behavior is an example of which attitude? A. Cultural blindness B. Cultural taboo C. Cultural imposition D. Acculturation

A. Cultural blindness

A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client? A. Digoxin immune FAB B. Ibuprofen C. Warfarin D. Amlodipine

A. Digoxin immune FAB

Which nursing intervention would best demonstrate evidence-based practice in maternal-child health care? A. Family-centered pediatric care B. Minimizing parental interaction with preterm infants C. Placing adults and children with similar diseases on the same unit D. Decentralizing care to allow clients to be closer to home

A. Family-centered pediatric care

A nurse overhears a colleague tell a client that based on the genetic testing results she should terminate the pregnancy. Which action is most appropriate for the nurse to take? A. Immediately stop the nurse. B. Call the client later and apologize. C. Contact the health care provider. D. Tell the unlicensed assistive personnel

A. Immediately stop the nurse.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Impaired skin integrity related to disease process D. Risk for infection related to breaks in the skin

A. Ineffective airway clearance related to edema of the respiratory passages

A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next? A. Question the client about alcohol and illicit drug use. B. Instruct the client to hold the breath and bear down. C. Prepare to administer a calcium channel blocker. D. Place the client on supplemental oxygen.

A. Question the client about alcohol and illicit drug use.

A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation? A. Stereotyping B. Cultural blindness C. Cultural conflict D. Cultural imposition

A. Stereotyping

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? A. Surgical asepsis B. Medical asepsis C. Universal precautions D. Contact precautions

A. Surgical asepsis

A client with heart failure is receiving furosemide, 40 mg I.V. The physician orders [40 mEq (40 mmol/L)] of potassium chloride in 100 ml of dextrose 5% in water to infuse over 4 hours. The client's most recent serum potassium level is [3.0 mEq/L (3.0 mmol/L)]. At what infusion rate should the nurse set the I.V. pump? A. 10 ml/hour B. 25 ml/hour C. 50 ml/hour D. 100 ml/hour

B. 25 ml/hour

After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom the student nurse has been assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response? A. Allow the student access to the medication record because the instructor has posted an assignment sheet. B. Ask the student to provide a photo ID for comparison with the names on the assignment sheet. C. Ask the student to contact the instructor by phone to verify the student's identification. D. Allow the student supervised access to the client's medication record.

B. Ask the student to provide a photo ID for comparison with the names on the assignment sheet.

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? A. Agnosia B. Ataxia C. Spasticity D. Rigidity

B. Ataxia

A woman has come to the clinic for her first prenatal visit. Which of the following would be the most effective way to initiate data gathering for a health history? A. Ask her to complete a written questionnaire concerning her past and present status. B. Conduct an interview in a private room to obtain her health history. C. Wait until she is in the examining room and prepared for her physical examination. D. Ask her some basic questions in the waiting room before taking her to the examining room.

B. Conduct an interview in a private room to obtain her health history.

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis? A. Preventing renal insufficiency B. Controlling seizures and increased intracranial pressure C. Maintaining hemodynamic stability and adequate cardiac output D. Preventing muscular atrophy

B. Controlling seizures and increased intracranial pressure

A client is to receive a radiocontrast media as part of a diagnostic scan. Which intervention is intended to reduce the nephrotoxic effects of the radiocontrast media? A. Having the client take nothing by mouth B. Increasing the normal saline intravenous infusion rate prior to the exam C. Administering one unit of packed red blood cells D. Administering ibuprofen 600 mg prior to the procedure

B. Increasing the normal saline intravenous infusion rate prior to the exam

Undersensing occurs as a pacemaker malfunctions. The nurse understands undersensing occurs as a result of which event? A. The complex does not follow the pacing spike B. Pacing spike occurs at the preset level C. Total absence of the pacing spike D. Loss of pacing artifact

B. Pacing spike occurs at the preset level

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? A. Impetigo B. Scabies C. Contact dermatitis D. Dermatophytosis

B. Scabies

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? A. The nurse leaves the room when a client is crying to provide privacy. B. The nurse uses open-ended questions when working with a crying client. C. The nurse documents the client was crying at the end of the shift. D. The nurse calls the hospital chaplain to talk with the client.

B. The nurse uses open-ended questions when working with a crying client.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? A. Both tests need to be done before breakfast. B. The ultrasonography should be scheduled before the GI procedure. C. The upper GI should be scheduled before the ultrasonography. D. The client may eat a light meal before either test.

B. The ultrasonography should be scheduled before the GI procedure.

Florence Nightingale was a nursing pioneer who challenged prejudices against women and elevated the status of all nurses. Which statement accurately describes one of her accomplishments? A. She established the fact that nursing is the same as medicine. B. She promoted the addition of nursing education as part of a medical degree. C. She established the tenets of the American Red Cross. D. She promoted the publication of books about nursing and health care.

B. She promoted the addition of nursing education as part of a medical degree.

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? A. Libel B. Slander C. Negligence D. Malpractice

B. Slander

It is important for home health care nurses to remember which point? A. The nurse is the primary caregiver. B. The nurse is the guest in the client's home. C. Rehabilitation is the major client goal. D. The nurse should act as a counselor and advisor.

B. The nurse is the guest in the client's home.

Nurses who value client advocacy follow what guideline? A. They value their loyalty to an employing institution or to a colleague over their commitment to their clients. B. They give priority to the good of the individual client rather than to the good of society in general. C. They choose the claims of the client's well-being over the claims of the client's autonomy. D. They make decisions for clients who are uninformed concerning their rights and opportunities.

B. They give priority to the good of the individual client rather than to the good of society in general.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? A. Nasal cannula B. Venturi mask C. T-piece D. Partial-rebreathing mask

B. Venturi mask

A nurse is providing education to a woman about screening for breast cancer. The woman has no symptoms and no family history of breast cancer. Which recommendation would the nurse make based on the guidelines from the American Cancer Society? A. biennial mammography beginning at age 50 B. annual mammogram beginning at age 40 C. clinical breast exam starting at age 30 D. no breast self-exam

B. annual mammogram beginning at age 40

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication? A. lateral rotation of the head and neck B. clear yellowish fluid on the dressing C. use of the standing position to void D. nonproductive cough

B. clear yellowish fluid on the dressing

A nurse is caring for a 9-year-old child who has a grave prognosis after receiving a closed injury from being struck by a car. Which health team member should approach the family about organ donation? A. nurse-manager B. transplant coordinator C. emergency department nurse D. pastoral care staff member

B. transplant coordinator

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom? A. Blurred vision B. Elevated IOP C. A mucopurulent ocular discharge D. Severe pain

C. A mucopurulent ocular discharge

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate? A. Monitor for faulty electrical equipment. B. Alert personnel who break sterile technique. C. Allow unnecessary personnel to enter the OR environment. D. Maintain the positive pressure OR environment.

C. Allow unnecessary personnel to enter the OR environment.

A nurse is assigned to work with a client who has a disability. The nurse believes that all people with disabilities have a poor quality of life and are dependent and nonproductive. What type of barrier will this client experience? A. Structural barrier B. Barrier to health care C. Attitudinal barrier D. Transportation barrier

C. Attitudinal barrier

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction? A. Empathy B. Transference C. Countertransference D. Modeling

C. Countertransference

A client is admitted with end-stage pancreatic cancer and is experiencing extreme pain. The client asks the nurse whether an acupuncturist can come to the hospital to help manage the pain. The nurse states, "You won't need acupuncture. We have pain medications." Which characteristic has the nurse displayed? A. Stereotyping B. Cultural conflict C. Cultural imposition D. Culture shock

C. Cultural imposition

A client is being taught to self-administer a narcotic analgesic by means of an intravenous PCA pump system. Which of the following would help prevent accidental overdosage? A. Reducing the dosage of the narcotic analgesic B. Reducing the frequency of administration of the narcotic analgesic C. Programming the dosage and time interval into the device D. Drawing up a schedule chart for the client

C. Programming the dosage and time interval into the device

A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task? A. Keep the side rails up. B. Position the overbed table away from the bed. C. Raise the bed to approximately waist level. D. Position the client on the far side of the bed.

C. Raise the bed to approximately waist level.

A client has been prescribed clozapine for schizoaffective disorder (SCA) with depression. The nurse should explain to the client that one advantage of clozapine is that it can provide what? A. Cost savings B. Weight loss C. Reduction of hospitalizations and risk for suicide D. Combination with lithium for greater effect

C. Reduction of hospitalizations and risk for suicide

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? A. Apical pulse B. Orthostatic blood pressure C. Respiratory rate and depth D. Urinary intake and output

C. Respiratory rate and depth

Parents of a preschooler with chickenpox ask the nurse about measures to make their child comfortable. The nurse instructs the parents to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? A. Guillain-Barré syndrome B. rheumatic fever C. Reye's syndrome D. scarlet fever

C. Reye's syndrome

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? A. Hand-held showers B. Wearing a scarf over the stoma C. Swimming D. Coughing

C. Swimming

You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements? A. They produce anorexia. B. They impair the immune system. C. They prolong bleeding. D. They lower high-density lipoprotein levels.

C. They prolong bleeding.

Which practice by the nurse indicates that the nurse is a professional? A. Doing things the way they have always been done B. Using intuition to make decisions about client care C. Using evidence-based practice interventions D. Submitting an article to a local newspaper

C. Using evidence-based practice interventions

Which registered nurse should be assigned to the client who had a chest tube inserted yesterday? A. a charge nurse pulled from the psychiatric unit B. a licensed practical nurse with 10 years of experience C. a registered nurse who use to work on the cardiovascular unit D. a registered nurse who worked as a head nurse on the orthopedic unit

C. a registered nurse who use to work on the cardiovascular unit

A client suffers from depression following the accidental death of a child. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the nurse learns that the client no longer wants to die. The nurse should: A. suggest that the client no longer requires close observation. B. place the client in a private room, away from the nurses' station, so that she has privacy to work through the stages of the grieving process. C. inspect the client's personal belongings for potentially dangerous objects. D. avoid any further discussion of suicide unless the client brings up the topic.

C. inspect the client's personal belongings for potentially dangerous objects.

A woman comes to the clinic reporting intense pruritus and a thick curd-like vaginal discharge. On examination, white plaques are observed on the vaginal wall. The nurse suspects which condition? A. trichomoniasis B. bacterial vaginosis C. vulvovaginal candidiasis D. chlamydia

C. vulvovaginal candidiasis

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."

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? A. Pupillary asymmetry B. Irregular breathing pattern C. Involuntary posturing D. Declining level of consciousness (LOC)

D. Declining level of consciousness (LOC)

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? A. Hair is pulled back and covered by a cap. B. Scrub top and drawstring are tucked into pants. C. Shoe covers are used. D. Mask is placed over nose and extends to bottom lip.

D. Mask is placed over nose and extends to bottom lip.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation? A. Report the incidents to the facility's lawyer. B. Remind the residents and family members not to leave valuables unattended. C. Pass the information on to the doctor and the next shift staff. D. Notify the supervisor and call the police.

D. Notify the supervisor and call the police.

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease? A. Blood urea nitrogen (BUN) level of 12 mg/dl B. Blood glucose level of 90 mg/dl C. Serum sodium level of 134 mEq/L D. Serum potassium level of 5.8 mEq/L

D. Serum potassium level of 5.8 mEq/L

Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? A. Trendelenburg position B. Lithotomy position C. Supine position D. Sims position

D. Sims position

A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status? A. The LPN speaks directly to the physician. B. The LPN informs the RN when a wound heals. C. The LPN informs the RN only if a wound worsens. D. The RN communicates daily with the LPN about the condition of each resident.

D. The RN communicates daily with the LPN about the condition of each resident.

What action by a nurse best promotes the ethical principle of justice? A. Advocating for enhanced mental health services in an underserved neighborhood B. Informing a client who is competent that the client has the right to discontinue treatment C. Clearly describing the potential adverse effects of a client's new pharmacologic treatment D. Obtaining written, informed consent from a client who has agreed to be in a research study

A. Advocating for enhanced mental health services in an underserved neighborhood

The nurse is caring for a 6-year-old child who has pyelonephritis. The use of what group of antibiotics would be contraindicated due to the client's age? A. Tetracyclines B. Penicillins C. Cephalosporins D. Aminoglycosides

A. Tetracyclines

In assessing a client, the nurse notes a grayish discharge from the vaginal area accompanied by a foul odor. What is the nurse's best action? A. Encouraging better hygiene B. Flushing the area with an antibiotic wash C. Applying an antifungal cream D. Asking about other symptoms

D. Asking about other symptoms