HESI review

An adult male who fell 20 ft from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the ER prior to his transfer to the ICU. The nurse notes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past HR 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A) Add sterile water to the suction control chamber B) Give blood from the collection chamber as autotransfusion C) Manipulate blood in tubing to drain into chamber D) Increase wall suction to eliminate fluctuation in water seal

A) Add sterile water to the suction control chamber

An older woman w/ a history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an INR value of 5.0. Upon admission, which prescription should the nurse expect to implement? A) Administer Vitamin K injection B) Start continuous heparin infusion C) Continue warfarin at same dose D) Transfusion unit of packed RBCs

A) Administer Vitamin K injection

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which medication should the nurse bring to the healthcare provider's attention? A) Allopurinol B) Furosemide C) Aspirin, low dose D) Enalapril

A) Allopurinol

The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL. When assessing the client, what is the priority? A) Assess for signs of fluid volume deficit B) Observe wound drainage characteristics C) Measure the level of acute pain D) Determine when the client last ate

A) Assess for signs of fluid volume deficit

A PT w/ leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this PT's plan of care? A) Assess urine and stool for occult blood B) Monitor for signs of activity intolerance C) Require visitors to wear respiratory masks D) Obtain client's temperature Q4 hours

A) Assess urine and stool for occult blood

A client in the ICU is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. What action should the nurse take first? A) Auscultate bilateral breath sounds B) Review the heart rhythm on cardiac monitor. C) Administer PRN dose of lorazepam D) Check urinary catheter for obstruction

A) Auscultate bilateral breath sounds

Which information is most important for the nurse to obtain when determining a PT's risk for obstructive sleep apnea syndrome? A) BMI B)Breath sounds C) Self-description of pain D) LOC

A) BMI

The nurse is assigning rooms for 4 PTs, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The PT w/ which condition should be assigned the only private room available? A) Bacterial meningitis B) Viral encephalitis C) Septic shock D) Brain abscess

A) Bacterial meningitis

The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the HCP? SATA A) Blurred vision B) Headache C) Lack of appetite D) Urinary frequency E) Chills and fever F) Swollen hands

A) Blurred vision B) Headache F) Swollen hands

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A) Check for a distended bladder B) Review the hemoglobin to determine hemorrhage C) Massage the uterus to decrease atony D) Increase intravenous infusion

A) Check for a distended bladder

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (SATA) A) Chicken broth B) Apple juice C) Hot chocolate D) Black coffee E) Orange juice

A) Chicken broth B) Apple juice

While caring for a PT's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the PT's lab values? A) Culture for sensitive organisms B) Serum blood glucose level C) Creatinine D) Serum albumin

A) Culture for sensitive organisms

An UAP is assigned to provide personal care for a PT whose prescribed activity is bedrest w/ bedside commode use. The UAP reports to the nurse that the PT is so obese that the UAP feels unable to safely assist the PT in transferring from the bed to the bedside commode. How should the nurse respond? A) Determine the PT's level of mobility and need for assistance B) Instruct the UAP that all PTs deserve equal care C) Advise the PT to maintain bedrest so that safety can be ensured D) Assign another UAP to care for the PT

A) Determine the PT's level of mobility and need for assistance

A client arrives on the surgical floor after major abdominal surgery. Which intervention should the nurse perform first? A) Determine the client's vital signs B) Assess the surgical site C) Apply warmed blankets D) Administer prescribed pain medication

A) Determine the client's vital signs

The nurse is assessing a PT who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the HCP immediately? A) Diminished breath sounds over the trocar insertion site B) Equal bilateral chest expansion C) Scattered crackles unchanged from baseline D) RR of 22 breaths/min

A) Diminished breath sounds over the trocar insertion site

The nurse is preparing to send a PT to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the PT leaves the medical unit? A) Document that the PT has remained NPO B) Confirm monitor reading in synchronous mode C) Notify the rapid response team of the transfer D) Secure cardioversion pads on the PT's chest

A) Document that the PT has remained NPO

Which instruction should the nurse provide a pregnant PT who is reporting heartburn? A) Eat small meals throughout the day to avoid a full stomach B) Take an antacid at bedtime and whenever symptoms worsen C) Maintain a sitting position for 2 hrs after eating D) Limit fluids between meals to avoid overdistension of the stomach

A) Eat small meals throughout the day to avoid a full stomach

An older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (SATA) A) Encourage family to participate in the client's care B) Play classical music in room while client is awake C) Suction oral cavity every 4 hours D) Place a bedside commode next to bed E) Measure neurological vital signs every 4 hours

A) Encourage family to participate in the client's care E) Measure neurological vital signs every 4 hours

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse? A) Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer B) Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food C) Instruct the client that these mild symptoms can generally be controlled with changes in his diet D) Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms

A) Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer

Which type of leukocyte is involved w/ allergic responses and the destruction of parasitic worms? A) Eosinophils B) Neutrophils C) Lymphocytes D) Monocytes

A) Eosinophils

After an inservice about EHR security and safeguarding PT information, the nurse observes a colleague going home w/ printed copies of PT information in a uniform pocket. Which action should the nurse take? A) File a detailed incident report w/ the specific hiring facility B) Warn the colleague that their actions are unprofessional C) Comment anonymously about the action on a staff discussion board D) Communicate the colleague's actions to the unit charge nurse

A) File a detailed incident report w/ the specific hiring facility

A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain? A) Frequency that the child uses a rescue inhaler during the week B) Type of allergen exposure or trigger for the current episode C) Type of inhaler the child typically uses on a regular basis D) Last dose and type of rescue used by the child

A) Frequency that the child uses a rescue inhaler during the week

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the PT's compliance w/ self care? A) Have the PT vocalize the instructions provided B) Ensure that someone will stay w/ the PT for 24 hrs C) Speak clearly and face the PT for lip reading D) Provide written instruction for eye drop administration

A) Have the PT vocalize the instructions provided

A PT has w/ Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The PT's lab values include: NA 129 mEq/L, glucose 54 mg/dl and K 5.3. When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medication A) Hydrocortisone B) Regular insulin C) Broad spectrum antibiotic D) Potassium chloride

A) Hydrocortisone

A young woman w/ multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A) Immunizations can trigger a relapse of the disease, so get plenty of extra rest B) These early signs of an infection may require medical treatment w/ antibiotics C) These are common side effects of the vaccines and will resolve in a few days D) Plans to move into the dormitory need to be postponed for at least a semester

A) Immunizations can trigger a relapse of the disease, so get plenty of extra rest

The nurse is caring for a PT admitted for evaluation of a descending aortic aneurysm. While outside the room documenting, the nurse hears the PT screaming. The PT tells the nurse that the pain is "sharp, like something inside is ripping and tearing." The PT also reports dizziness. Which of the following is the likely cause? A) Impending rupture of the aneurysm B) The PT is having a panic attack C) Clotting of the aneurysm D) The PT is hallucinating from the opioids

A) Impending rupture of the aneurysm

When conducting diet teaching for a PT who is on a postoperative full liquid diet, which foods should the nurse encourage the PT to eat? SATA A) Lentils B) Potato soup C) Tea D) Cheese E) Whole grain breads

A) Lentils B) Potato soup C) Tea

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse? A) Measure the PT's body weight each morning B) Establish BP parameters for PT monitoring C) Evaluate a staff member providing wound care D) Evaluate PT teaching through return demonstration

A) Measure the PT's body weight each morning

The nurse caring for a child w/ mononucleosis can expect the child to exhibit which symptoms? A) Positive Epstein-Barr, and malaise B) Ear pain and fever C) Elevated WBC and sedimentation rate D) Increased BUN and serum creatinine

A) Positive Epstein-Barr, and malaise

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? A) Potassium B) Calcium C) Protein D) Hemoglobin

A) Potassium

A female child is brought to the emergency department after awakening with a bark-like cough and stridor. Upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement? A) Prepare for emergency tracheotomy B) Assess the child for dehydration C) Collect midstream urine specimen for culture D) Examine oropharyngeal area for foreign body

A) Prepare for emergency tracheotomy

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting? A) Provide information on ways to increase activity for the family B) Have several teachers talk about health risks associated w/ obesity C) Distribute a shopping list of suggested healthy snack items D) Determine the parent's degree of concern about it

A) Provide information on ways to increase activity for the family

A low risk primigravida at 28 weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? A) Pulse increase of 10 beats/minute B) Fundal height of 22 centimeters C) Glucosuria D) Proteinuria

A) Pulse increase of 10 beats/minute

The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two new clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment? A) RN completes the two admission assessments. One PN completes the blood glucose measurements, and one PN completes the postoperative visit B) RN completes the postoperative visit and two blood glucose measurements. Each PN completes one admission assessment C) RN completes one admission and the postoperative visit. One PN completes the blood glucoses measurements, one PN completes an admission assessment D) RN completes the postoperative visit. Each PN completes one admission assessment and one blood glucose measurement

A) RN completes the two admission assessments. One PN completes the blood glucose measurements, and one PN completes the postoperative visit

A PT w/ cirrhosis of the liver is admitted w/ complications r/t end stage liver disease. Which interventions should the nurse implement? SATA A) Report serum albumin and globulin lvls B) Provide diet low in phosphorus C) Note signs of swelling and edema D) Monitor abnormal girth E) Increase oral fluid intake to 1,500 mL daily

A) Report serum albumin and globulin lvls C) Note signs of swelling and edema D) Monitor abnormal girth

An older male PT who was successfully treated for shingles with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? A) Review the medication record to determine when the analgesic was administered B) Reassure the PT that the infection is resolved and the pain should soon disappear C) Teach the PT about the importance of completing the full course of antiviral medication D) Contact the HCP about the need to resume the PT's antiviral medication

A) Review the medication record to determine when the analgesic was administered

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gain. Which assessment is most important for the nurse to report to the healthcare provider? A) Serum lithium level of 1.6 mEq/L or mmo/L B) Six hours of sleep in the past 3 days C) Weight loss of 10 lbs in past month D) Blood alcohol level of 0.09%

A) Serum lithium level of 1.6 mEq/L or mmo/L

Which snack selection indicates to the nurse that a school-aged boy w/ gastroesophageal reflux understands his dietary restrictions? A) Sugar cookies B) Pizza C) Chocolate milkshake D) Tacos

A) Sugar cookies

What statement by a PT who is 24 hrs post-subtotal thyroidectomy requires an immediate investigation by the nurse? A) When I get out of bed quickly, I feel a little dizzy B) The dressing over my incision feels like it is too tight C) I'm most comfortable when the head of the bed is raised D) This IV infusion makes me urinate more often than usual

A) When I get out of bed quickly, I feel a little dizzy

Which conditions are most likely to respond to treatment with antihistamines? (SATA) A) Bronchitis B) Allergic rhinitis C) Otitis media D) Contact dermatitis E) Myocarditis

B) Allergic rhinitis D) Contact dermatitis

The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic Hep B immunizations? A) A child daycare worker who has a history of type II diabetes B) An office worker who requires hemodialysis for CKD C) A restaurant chef who was diagnosed one year ago w/ Hep A D) A sales person who travels internationally and eats food in foreign countries

B) An office worker who requires hemodialysis for CKD

An older client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the post-procedure care in the outpatient surgical unit? A) Arrange food on the plate in clockwise order B) Apply bilateral eye patched while sleeping C) Verbally identify self when entering the room D) Use a white board to communicate ideas

B) Apply bilateral eye patched while sleeping

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first? A) Provide a printed health care assessment form. B) Assess the surroundings for noise and distractions C) Ask the family member to answer the questions D) Defer the health history until the client is less anxious

B) Assess the surroundings for noise and distractions

The nurse observes a client prepare a meal in the kitchen of rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (SATA) A) Leans forward to pull a pan from a high shelf B) Bends from the waist to pick trash off the floor C) Locks knees while preparing food on the counter D) Brings a heavy can close to the body before lifting E) Widens stance while working near the sink

B) Bends from the waist to pick trash off the floor D) Brings a heavy can close to the body before lifting

When caring for a PT w/ full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention? SATA A) Sloughing tissue around wound edges B) Complaint of increased pain and pressure C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity E) Weeping serosanguineous fluid from the wound

B) Complaint of increased pain and pressure C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? A) Administer IV atropine B) Defibrillate with one shock C) Give a dose of amiodarone IV D) Prepare for external pacing

B) Defibrillate with one shock

A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? A) Suggest the nurse use a 20-gauge B) Direct the nurse to change IV tubing C) Instruct the nurse to remove the needle D) Prompt the nurse to apply pressure to the site

B) Direct the nurse to change IV tubing

A PT arrives for an annual physical exam and complains of having calf pain. The PT's health history reveals peripheral arterial disease. Which question should the nurse ask the PT about expected findings r/t chronic arterial symptoms? A) Were your legs ever suddenly swollen, red, warm, and painful? B) Does the calf pain occur when walking short distances? C) Did you receive treatment for weeping ulcers on lower legs? D) Have you ever experienced ankle edema and varicose veins?

B) Does the calf pain occur when walking short distances?

A 12 y/o PT who had an appendectomy 2 days ago is receiving 0.9% normal saline at 50 mL/hr. The PT's urine specific gravity is 1.035. What action should the nurse implement? A) Assess bowel sounds in all quadrants B) Encourage popsicles and fluids of choice C) Evaluate postural blood pressure measurements D) Obtain a specimen for urinalysis

B) Encourage popsicles and fluids of choice

A PT is admitted to the ICU w/ syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A) Patch one eye B) Evaluate swallow C) Reorient often D) Range of motion

B) Evaluate swallow

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? A) Reports left chest wall pain prior to admission B) Experiences facial swelling after eating crab C) Verbalizes a fear of being in a confined space D) Drank a glass of water in the past 2 hours

B) Experiences facial swelling after eating crab

An adult male was diagnosed with stage IV lung cancer 3 weeks ago. His wife approaches the nurse and asks how will she know that her husband's death is imminent because their 2 children want to be there when he dies. Which is the best response by the nurse? A) Gather information regarding how long it will take for the children to arrive B) Explain that the PT will start to lose consciousness and the body systems will slow down C) Reassure the spouse that the healthcare provider will notify when to call the children D) Offer to discuss the PT's health status with each of the adult children

B) Explain that the PT will start to lose consciousness and the body systems will slow down

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2-3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care? A) Analyze past hurts and resentments to identify the source B) Focus on small achievable tasks, not taxing problems C) Concentrate on and ventilate emotions when distressed D) Relax and reduce the amount of effort to solve the problem

B) Focus on small achievable tasks, not taxing problems

A PT is receiving IV heparin and oral warfarin after a pulmonary embolism. The nurse determines the PT's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A) Withhold the heparin and continue the same dose of warfarin B) Increase the warfarin dose C) Decrease the heparin dose D) Increase the heparin dose and decrease the warfarin dose

B) Increase the warfarin dose

A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is MOST important for this client to receive? A) Furosemide B) Lactulose C) Loperamide D) IV human albumin

B) Lactulose

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? A) Administer a hypertonic IV fluids as prescribed B) Limit oral water intake C) Assess neurological status every 8 hours D) Initiate seizure precautions

B) Limit oral water intake

A PT w/ a history of using illicit drug intravenously is admitted w/ Kaposi's sarcoma. Which intervention should the nurse include in this PT's admission plan of care? A) Assess for symptoms of AIDs dementia B) Monitor for secondary infections C) Identify local support HIV support groups D) Observe for adverse drug reactions

B) Monitor for secondary infections

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? A) Identifies 2 treatments for constipation due to immobility. B) Names 3 home safety hazards to be resolved immediately. C) States 4 risk factors for the development of osteoporosis. D) Lists 5 calcium-rich foods to be added to her daily diet.

B) Names 3 home safety hazards to be resolved immediately.

An older adult male who is in his early 70's is admitted to the ER because of a COPD exacerbation. The PT is struggling to breath and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the PT, asks the nurse to stop the procedure and provides the nurse a copy of the PT's living will. What action should the nurse take? A) Facilitate a family meeting / the palliative care team B) Notify the healthcare provider of the PT's wishes C) Place a certified copy of the living will in the PT's record D) Alert the nursing staff of the PT's DNR status

B) Notify the healthcare provider of the PT's wishes

A client with cellulitis of the right great toe has been taking an antibiotic for 7 days. Which assessment should the nurse complete to determine the effectiveness of the medication? A) Note any thickening, scarring, or ridge lines present on the toe. B) Observe for signs of inflammation on and surrounding the toe. C) Determine the length of the capillary refill time of the toe D) Compare the pedal pulse volumes of the right and left feet

B) Observe for signs of inflammation on and surrounding the toe.

A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The clients arterial blood gases indicate respiratory acidosis. An increase in which lab test result supports this finding? A) Arterial pH B) PaCO2 C) HCO3 D)PaO2

B) PaCO2

The nurse is providing teaching to a client who has been recently diagnosed with gestation diabetes mellitus. Which complication poses the GREATEST risk to the fetus is euglycemia is not maintained? A) Cleft palate B) Preterm birth C) Low birth weight D) Macrosomic newborn

B) Preterm birth

The nurse is feeding a client who was admitted this morning with syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? A) Elevate head of bed for 30 mins B) Provide nectar thickened liquids C) Allow small amounts of liquid with meals D) Perform oral care before meals

B) Provide nectar thickened liquids

Following morning care, a client with a c-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first? A) Teach the client to recognize symptoms of dysreflexia B) Relieve any kinks or obstruction in the client's foley tubing C) Administer a prescribed PRN dose of hydralazine D) Assess the client's blood pressure every 15 minutes

B) Relieve any kinks or obstruction in the client's foley tubing

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? A) Report any allergies to shellfish or iodine B) Report any painful urination, blood in urine, or fever C) Lay prone for 24 hours after the procedure D) Avoid strenuous activity and sports for at least 2 weeks

B) Report any painful urination, blood in urine, or fever

A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? A) Check the client's hemoglobin level B) Review the client's current list of medications C) Assess the client for the presence of hemorrhoids D) Administer a prescribed PRN antiemetic

B) Review the client's current list of medications

A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider? A) Volume of each voiding is more than 300 mL B) Serum potassium level is elevated C) Relief of flank pain that radiated into the groin. D) Hematuria that is beginning to turn pink

B) Serum potassium level is elevated

Which lab results should the nurse closely monitor in a PT who has end-stage renal disease? A) Leukocytes, neutrophils, and thyroxine B) Serum potassium, calcium, and phosphorus C) BP, HR, and temp D) Erythrocytes, hemoglobin, and hematocrit

B) Serum potassium, calcium, and phosphorus

When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A) Crying B) Sitting upright C) Vomiting D) Straining on stool

B) Sitting upright

A male PT w/ right-sided weakness calls for assistance w/ ambulating to the bathroom. What action should the nurse implement? A) Bring a bedside commode to the PT B) Stand on the PT's right side as he walks C) Walk directly behind the PT to prevent a fall D) Give the PT a cane to hold in his right hand

B) Stand on the PT's right side as he walks

The nursing staff on a medical unit includes a registered nurse, a practical nurse, and an unlicensed assistive personnel. Which task should the charge nurse assign to the RN? A) Transport a client who is receiving IV fluids to the radiology department B) Supervise a newly hired graduate nurse during an admission assessment C) Complete ongoing focused assessments of a client with wrist restraints D) Administer PRN oral analgesics to a client with a history of chronic pain

B) Supervise a newly hired graduate nurse during an admission assessment

After receiving report on an inpatient acute care unit, which client should the nurse assess first? A) The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid B) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity C) The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds D) The client with an obstruction of the large intestine who is experiencing abdominal distension

B) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

The nurse is teaching a PT newly diagnosed w/ systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide? A) The PT can expect to progressively get lose function in a fairly predictable sequence. B) The disease is characterized by alternating periods of flare-ups and remissions C) Once an acute attack subsides, the PT can expect to feel fine again D) Systemic lupus erythematosus is a chronic, incurable, terminal illness

B) The disease is characterized by alternating periods of flare-ups and remissions

A client who is admitted to the ICU with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasing anxious and complains of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A) Continuous bubbling in the water-seal chamber B) Tracheal deviation toward the left lung C) Decreased bright red bloody drainage D) Tachypnea with difficulty breathing

B) Tracheal deviation toward the left lung

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (SATA) A) Avoid range of motion exercises B) Use a residual limb shrinker C) Wash the stump with soap and water D) Inspect skin for redness E) Apply alcohol to the stump after bathing

B) Use a residual limb shrinker C) Wash the stump with soap and water D) Inspect skin for redness

While caring for a toddler receiving O2 via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A) Use a topical lidocaine analgesic for cracked lips B) Use a water soluble lubricant on affected oral and nasal mucosa C) Ask the mother what she usually uses on the child's lips and nose D) Apply a petroleum jelly to the child's nose and lips

B) Use a water soluble lubricant on affected oral and nasal mucosa

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A) Regional relocation center for earthquake victims B) Vitamin supplements for high-risk pregnant women C) Lead screening for children in low-income housing D) Case management and screening for PTs w/ HIV

B) Vitamin supplements for high-risk pregnant women

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? A) "What would you like to see me do to protect you?" B) "You are in a safe place. No one can get to you here." C) "You seem quite frightened right now." D) "There is no one who will hurt you."

C) "You seem quite frightened right now."

The psychiatric nurse is caring for PTs on an adolescent unit. Which PT requires the nurse's immediate attention? A) A 16 y/o PT diagnosed w/ major depression who refuses to participate in group B) A 14 y/o PT w/ anorexia nervosa who is refusing to eat the evening snack C) An 18 y/o PT w/ antisocial behavior who is being yelled at by other PTs D) A 17 y/o PT diagnosed w/ bipolar disorder who is pacing around the lobby

C) An 18 y/o PT w/ antisocial behavior who is being yelled at by other PTs

Which class of drugs is the only source of a cure for septic shock? A) Anticholesteremics B) Antihypertensives C) Antiinfectives D) Antihistamines

C) Antiinfectives

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is most important for the nurse to include in this client's plan of care for today? A) Schedule client for a group that focuses on self-esteem B) Help client to develop a list of daily affirmations C) Assist client in identifying goals for the day D) Encourage client to participate for one hour in a team sport

C) Assist client in identifying goals for the day

The nurse is caring for a PT who is admitted to the ER after a motor vehicle accident. The PT begins to experience a decreased LOC and the pupils do not respond equally to light. Which vital signs changes indicate the PT is manifesting Cushing's triad? A) BP of 80/40, weak HR of 40, Cheyne-Stokes RR of 10 B) BP of 180/120, weak HR of 92, Kussmaul respirations of 18 C) BP of 180/80, bounding HR of 50, respirations of 30 w/ apneic episodes D) BP of 90/60, strong HR of 60, eupneic RR of 16

C) BP of 180/80, bounding HR of 50, respirations of 30 w/ apneic episodes

A PT who received hemodialysis yesterday is experiencing a BP of 200/100 mmHg, HR 110 bpm, and RR 36 breaths/min. The PT manifesting SOB, bilateral 2+ pedal edema, and an O2 sat of 89%. Which action should the nurse take first? A) Elevate the foot of the bed B) Restrict the PT's fluids C) Begin supplemental O2 D) Prepare PT for hemodialysis

C) Begin supplemental O2

A PT is admitted w/ the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the PT's care? A) Depression B) Peripheral neuropathy C) Confusion D) Right lower abdominal pain

C) Confusion

A PT is admitted w/ acute pancreatitis. The PT admits to drinking a pint of bourbon daily. The nurse medicates the PT for pain and monitors vital signs every 2 HRs. Which finding should the nurse report immediately to the healthcare provider? A) Anorexia and abdominal distension B) Abdominal pain and vomiting C) Confusion and tremors D) Yellowing and itching of skin

C) Confusion and tremors

The nurse is caring for a PT who is entering the 2nd stage of labor. Which action should the nurse implement first? A) Prepare the PT for spinal anesthesia B) Empty the PT's bladder using a straight catheter C) Convery to the PT that birth is imminent D) Prepare the coach to accompany the PT to delivery

C) Convery to the PT that birth is imminent

The nurse observes a PN pouring warm water over the perineal area of a female PT who has frequent urinary incontinence while the PT is positioned on a bed pan. Which action should the nurse take? A) Instruct the PN that this technique promotes infection in elderly females B) Recommend a complete bath to cleanse the perineal area more fully C) Evaluate the effectiveness of this measure to stimulate PT voiding D) Suggest contacting the HCP for a prescription for catheter insertion

C) Evaluate the effectiveness of this measure to stimulate PT voiding

In caring for a PT w/ Cushing's syndrome, which serum lab value is most important for the nurse to monitor? A) Creatinine B) Lactate C) Glucose D) Hemoglobin

C) Glucose

A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits? A) Teach parents about poison prevention B) Lavage activated charcoal before giving acetylcysteine dose C) If does is vomited within 1 hour of administration, repeat that oral dose D) Obtain blood samples to monitor liver function

C) If does is vomited within 1 hour of administration, repeat that oral dose

After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed w/ rheumatoid arthritis, and the HCP prescribes prednisone. Which education should the nurse provide the PT w/ regard to taking prednisone? A) Take prednisone doses before meals on an empty stomach B) Wear sunglasses when exposed to bright sunlight C) If sequential doses are missed, notify the HCP D) Schedule a monthly lab visit for a CBC

C) If sequential doses are missed, notify the HCP

A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the BEST initial nursing action? A) Administer naloxone per PRN protocol B) Obtain a serum drug screen C) Initiate seizure precautions D) Instruct the family about withdrawal symptoms

C) Initiate seizure precautions

A client with chronic renal insufficiency is preparing for the discharge from the hospital. Which information is most important for the nurse to include in this client's discharge teaching? A) Use of topical applications to manage pruritis B) Need for maintaining good oral hygiene C) Instructions regarding a restricted protein diet D) Strategies to promote independent self-care

C) Instructions regarding a restricted protein diet

An older client arrives to the emergency department (ED) with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature 95.4F, heart rate 112 beats/minute, respirations 14 breaths/minute, and blood pressure 74/37 mmHg. Which intervention is most important for the nurse to implement? A) Maintain strict intake and output B) Monitor blood glucose level C) Keep head of bed raised 45 degrees D) Assess warmth of extremities

C) Keep head of bed raised 45 degrees

The nurse is assessing a 4-year-old with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? A) Bathe the child daily with bath oil B) Apply baby lotion to the skin twice daily C) Keep the nails trimmed short D) Allow the child to wear only 100% cotton clothing

C) Keep the nails trimmed short

The nurse is caring for a seated PT who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? SATA A) Insert a bite block B) Restrain the client C) Loosen restrictive clothing D) Note the duration of the seizure E) Ease the PT to the floor

C) Loosen restrictive clothing D) Note the duration of the seizure E) Ease the PT to the floor

A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care? A) Evaluate hourly urine output for return of normal renal function B) Assess glucose via fingerstick every 4 to 6 hours C) Monitor the client's cardiac activity via telemetry D) Maintain venous access with an infusion of normal saline.

C) Monitor the client's cardiac activity via telemetry

A client with deep vein thrombosis in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? A) Encourage mobilization to prevent pulmonary embolism B) Assess blood pressure and heart rate at least every 4 hours C) Observe for bleeding side effects related to heparin therapy D) Measure each calf's girth to evaluate edema in the affected leg

C) Observe for bleeding side effects related to heparin therapy

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids". What nursing intervention is most useful in assisting the resident to meet this goal? A) Increase fluids provided with client's meals B) Record the client's intake and output every shift C) Offer glass of fluid every hour while awake D) Maintain a full pitcher of water at the bedside

C) Offer glass of fluid every hour while awake

The nurse is evaluating a tertiary prevention program for PTs w/ cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective? A) At-risk PTs received an increased number of routine health screenings B) PTs reported having new confidence in making healthy food choices. C) PTs who incurred disease complications promptly received rehab D) PT relapse of 30% in a 5-year community wide anti-smoking campaign

C) PTs who incurred disease complications promptly received rehab

A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident. The nurse should request a referral for a speech therapy if the client exhibits which finding? A) Unilateral facial drooping B) Abnormal response for cranial nerves I and II C) Persistent coughing while drinking D) Inappropriate mood swings

C) Persistent coughing while drinking

The nurse observes an UAP applying an alcohol-based hand rub while leaving a PT's room after taking vital signs. What action should the nurse take? A) Instruct the UAP to return to the PT's room to perform handwashing B) Supervise the UAP in the next PT's room to evaluate hand hygiene C) Remind the UAP to continue rubbing the hands together until they are dry D) Advise the UAP to wear gloves when obtaining vital signs for all PTs

C) Remind the UAP to continue rubbing the hands together until they are dry

Which laboratory values are critical for the nurse to monitor for a client who is experiencing thyrotoxic crisis? A) Blood and urine culture B) Glucose and calcium levels C) Renal and liver function tests D) Electrolytes and hemoglobin

C) Renal and liver function tests

Following a total knee replacement, a PT is discharged from the hospital w/ a prescription for warfarin. In reviewing discharge teaching, the PT tells the nurse that he will avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond? A) Discuss necessary fluid restrictions as well as food restrictions B) Explain that no dietary restrictions are needed w/ warfarin C) Review teaching about the effects of food rich in Vitamin K D) Provide a written list of additional foods high in potassium

C) Review teaching about the effects of food rich in Vitamin K

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? A) Observe the stool for a clay-colored appearance B) Obtain a specimen for culture and sensitivity analysis C) Send a stool sample to the lab for a guaiac test D) Assess for fatty yellow streaks in the client's stool

C) Send a stool sample to the lab for a guaiac test

A male PT on the psych unit is making sexual advance towards a female nurse. Which action should this nurse implement first? A) Document as specifically as possible the PT's behavior in the nurse's notes B) Discuss w/ the client why he is making sexual advances towards the nurse C) Tell the PT in a matter-of-fact manner to stop the sexual advances D) Request an immediate team meeting to discuss the inappropriate behavior

C) Tell the PT in a matter-of-fact manner to stop the sexual advances

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide? A) The quarter should be secured with an elastic bandage wrap B) An abdominal binder can be worn daily to reduce the protrusion C) This hernia is a normal variation that resolves without treatment D) Restrictive clothing will be adequate to help the hernia go away

C) This hernia is a normal variation that resolves without treatment

An older client returns to the clinic and receives refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill could be substituted for many of the others. Which instruction should the nurse implement to address the client's concerns? A) Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider B) Make certain a family member knows the name and use of all medications currently being taken C) Use a medication reminder system to prevent forgetting to take the right medications at the right time D) Bring all medications supplements, and herbs currently being taken to the next clinic appointment.

C) Use a medication reminder system to prevent forgetting to take the right medications at the right time

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? A) Frequently apply moisturizers to prevent dry skin B) Protect the site from getting wet during bathing C) Use a sponge to debride the affected area D) Gently pat the skin dry after rinsing with water

C) Use a sponge to debride the affected area

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A) Increase oxygen to 6 liters/minute B) Call for an Ambu resuscitation bag C) Assist the client to lie back in bed D) Administer a nebulizer treatment

D) Administer a nebulizer treatment

A client with peptic ulcer disease receives a prescription for intermittent suction via a Salem Sump nasogastric tube (NGT). After inserting the NGT and obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complains of nausea. Which action should the nurse implement first? A) Connect the NGT to low intermittent suction B) Irrigate the NGT with sterile normal saline C) Provide oral suction using a Yankauer tip D) Administer a prescribed antiemetic agent

D) Administer a prescribed antiemetic agent

The charge nurse of a critical care unit is informed at the beginning of the shift that less that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a RN? A) A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B) A 34 y/o admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a foley catheter C) A 63 y/o chain smoker admitter w/ chronic bronchitis who is receiving O2 via nasal cannula and has a saline lock D) An 82 y/o PT w/ Alzheimer's disease and a newly-fractured femur who has a foley catheter and soft wrist restraints applied

D) An 82 y/o PT w/ Alzheimer's disease and a newly-fractured femur who has a foley catheter and soft wrist restraints applied

After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care? A) Observe for signs of depression B) Monitor for urinary incontinence C) Provide a wide variety of meal choices D) Apply sequential compression stockings

D) Apply sequential compression stockings

The nurse is caring for a PT w/ chronic obstructive pulmonary disease (COPD) who uses O2 at 2 L/min per nasal cannula continuously. The nurse observes that the PT is having increased SOB w/ respirations at 23 breaths/minute. Which action should the nurse implement first? A) Determine if the PT is experiencing any anxiety B) Auscultate the PT's bilateral lung sounds and O2 saturation C) Notify the healthcare provider about the PT's distress D) Assess the delivery mechanism of the O2 tank, tubing, and cannula

D) Assess the delivery mechanism of the O2 tank, tubing, and cannula

A male PT who fell of a roof has right and left femur fractures and crushing injuries to both ankles. He is supine w/ bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hrs. When asked to evaluate his pain on a scale of 1-10, he screams 20. For the last 4 hrs, he has received morphine 2 mg IV hourly. His vital signs are HR 130 bpm, RR 32 breaths/min, BP180/90. Which intervention is most important for the nurse to implement? A) Request the HCP to consider a different analgesic B) Evaluate the traction for amount of tension applied to each extremity C) Determine if PT is experiencing cumulative effects of the total dosage D) Assess the extremities for signs of compartment syndrome Q2 hours

D) Assess the extremities for signs of compartment syndrome Q2 hours

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation is 62%. Which action should the nurse take first? A) Call respiratory therapy B) Monitor oxygen saturation levels every 5 minutes C) Silence the alarm and call the technician D) Begin manual ventilation immediately

D) Begin manual ventilation immediately

An adult PT is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes 2 hours or longer to complete. The PT worries about staying clean and refuses to sit on any of the chairs in the day area. This PT's handwashing is an example of which clinical behavior? A) Phobia B) Addiction C) Obsession D) Compulsion

D) Compulsion

After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take NEXT? A) Note the presence of an auscultatory gap B) Reinflate the cuff to a higher number C) Reposition the stethoscope over the brachial artery D) Continue with the blood pressure assessment

D) Continue with the blood pressure assessment

The practical nurse is preparing a client for a lumbar puncture. The nurse observes the PN turning the client on the side with the legs straight and the head of the bed in semi-Fowler's position. Which action should the nurse implement? A) Arrange for an unlicensed assistive personnel to assist the PN during the procedure B) Acknowledge that the PN has positioned the client safely and correctly C) Assume care of the client and assign the PN to the care of a different client D) Demonstrate to the PN how to position the client more effectively for the procedure

D) Demonstrate to the PN how to position the client more effectively for the procedure

The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli? A) Chills and tremors B) Nausea and vomiting C) Increased blood pressure D) Difficulty breathing

D) Difficulty breathing

An adult PT is admitted to the ER after falling from a ladder. While waiting to have a CT scan, the PT requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the PT asks for something stronger. Which intervention should the nurse implement? A) Assess PT's pupils for their reaction light B) Request that the CT scan be done immediately C) Review PT's history for use of illicit drugs D) Explain the reason for using non-narcotics

D) Explain the reason for using non-narcotics

A clinical trial is recommended for a female PT w/ metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The PT's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A) Explain to the family that they must accept their mother's decision B) Discuss success of clinical trials and ask the PT to consider participating for one month C) Ask the PT w/ her children present if she fully understands the decision she has made D) Explore the PT's decision to refuse treatment and offer support

D) Explore the PT's decision to refuse treatment and offer support

A 41 week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of Oxytocin? A) Regular contractions occurring every 10 minutes B) Sterile vaginal exam revealing 3 cm dilation C) Biophysical profile results showing oligohydramnios D) Fetal heart tone located in upper right quadrant

D) Fetal heart tone located in upper right quadrant

The healthcare provider prescribes methylergonovine maleate for a postpartum PT w/ uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A) Difficulty locating the uterine fundus B) Excessive lochia C) Saturation of more than one pad per hr D) HTN

D) HTN

In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? A) Elevated thyroid hormone level B) Systolic murmur C) Heart rate of 92 bpm D) Hematocrit of 28%

D) Hematocrit of 28%

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A) Erythrocyte sedimentation rate B) Serum calcium C) Osmolality D) Hemoglobin

D) Hemoglobin

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a NG tube to suction and is receiving lactated ringer's solution at 75 mL/hr IV. One hr after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's HR is 155 bpm, and his blood pressure is 78/48 mmHg in addition to reporting the findings to the surgeon, which action should the nurse implement first? A) Measure and document the client's urinary output B) Request the client's reserved unit of packed RBCs C) Prepare for placement of a central venous catheter D) Increase the infusion rate of Lactated Ringer's solution

D) Increase the infusion rate of Lactated Ringer's solution

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurses station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care? A) Deficient knowledge of lifestyle changes B) Decisional conflict due to stress C) Anxiety related to treatment plan D) Ineffective coping related to denial

D) Ineffective coping related to denial

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? A) Determine if the newborn is in the nursery B) Activate the lockdown procedure C) Ask the mother if any visitors were expected to arrive D) Match ID bands of all infants and mothers on the unit

D) Match ID bands of all infants and mothers on the unit

When caring for a PT w/ a TBI who had a craniotomy for ICP, the nurse assesses the PT using the GCS every 2 hrs. For the past 8 hrs the PT's GCS score has been 14. What does the GCS finding indicate about this client? A) Rehab prognosis is an expected full recovery B) Risk for irreversible cerebral damage r/t increased ICP C) Insertion of an ICP monitoring device is necessary D) Neurologically stable w/o indications of an increased ICP

D) Neurologically stable w/o indications of an increased ICP

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration. The medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 mins after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? A) Client reports being anxious B) Extreme agitation with staff and family C) An apical pulse of 120 beats per minute D) No wheezing upon auscultation of the chest

D) No wheezing upon auscultation of the chest

Which client's vital signs indicating increased intercranial pressure should the nurse report to the healthcare provider? A) P 70, BP 120/60, P 100, BP 90/60; rapid respirations B) P 110, BP 130/70; P 100 BP 110/70; shallow respirations C) P 130, BP 190/90; P 136, BP 200/100; Kussmaul respirations D) P 55, BP 160/70; P 50, BP 194/70 mmHg; irregular respirations

D) P 55, BP 160/70; P 50, BP 194/70 mmHg; irregular respirations

To prevent medication errors by an older PT who is sometimes confused, which intervention by the home health nurse is likely to be most effective? A) Have a family member administer medications B) Encourage taking medications at the same times daily C) Instruct the PT to wear glasses when reading labels D) Provide education both verbally and in written format

D) Provide education both verbally and in written format

A client with renal lithiasis is receiving morphine sulfate every 4 hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone? A) Complaints of increasing flank pain B) Unresponsive to verbal or tactile stimuli C) Statement about visual hallucinations D) Respiratory rate of 12 breaths/minute

D) Respiratory rate of 12 breaths/minute

The nurse is assigned to care for a PT diagnosed w/ psoriasis. Which behavior by the nurse addresses this PT's psychosocial need for acceptance? A) Encouraging the PT to join a support group B) Wearing gloves when interviewing the PT C) Allowing the PT to ventilate feelings D) Shaking the PT's hand during an introduction

D) Shaking the PT's hand during an introduction

An older PT is admitted w/ fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? A) Urine specific gravity is 1.040 B) Systemic blood pressure decreases 10 points when standing C) The client denies being thirsty D) Skin tenting occurs when the PT's forearm is pinched

D) Skin tenting occurs when the PT's forearm is pinched

A client who is pregnant seems confused and presents with the onset of headache, polyuria, and blurry vision. Which action should the nurse implement? A) Assess client for signs of vertigo B) Palpate bladder for urinary retention C) Determine serum potassium (K) level D) Take serial blood pressure readings

D) Take serial blood pressure readings

An older male was recently admitted to the rehab unit w/ unilateral neglect syndrome as the result of a cerebrovascular accident. Which action should the nurse include in the plan of care? A) Use hand and arm gestures to improve communication and comprehension B) Provide additional light in the room to promote sensory stimulation C) Place a clock and calendar in the room to improve orientation D) Teach the PT to turn his head from side to side for visual scanning

D) Teach the PT to turn his head from side to side for visual scanning

The nurse is developing a plan of care for a PT who reports tingling of the feet and who is newly diagnosed w/ peripheral vascular disease. Which outcome should the nurse include in the plan of care for this PT? A) The PT will express acceptance of their newly diagnosed health status B) The nurse will encourage the PT to walk 30 mins a day C) The PT's BP readings will be less than 160/90 mmHg D) The PT's skin on the lower legs will be intact at the next clinic visit

D) The PT's skin on the lower legs will be intact at the next clinic visit

The nurse is caring for 4 PTs: PT A, who has emphysema and whose O2 saturation is 94%; PT B, w/ a postoperative hemoglobin of 8.2 mg/dL; PT C, newly admitted w/ a potassium level of 3.8 mEq/L; and PT D, scheduled for an appendectomy who has a WBC count of 14,000 mm3. What intervention should the nurse implement? A) Move PT D into an isolation room 24 hrs before surgery B) Increase PT A's O2 to 4 L/min per cannula C) Ask the dietician to add a banana to PT C's breakfast tray D) Verify that PT B has two units of packed cells available

D) Verify that PT B has two units of packed cells available

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? ( Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.) Initiate an adverse event report. Stop the infusion Assess vital signs Document reaction to the drug Contact the healthcare provider

1) Stop the infusion 2) Assess vital signs 3) Contact the healthcare provider 4) Document reaction to the drug 5) Initiate an adverse event report.

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is BEST for administering this prescription? A) 1000, 1600, 2200, 0400. B) 0800, 1200, 1600, 2000 C) Administer with meals and a bedtime snack D) Give in equally divided doses during waking hours

A) 1000, 1600, 2200, 0400.

The nurse is caring for a client who reports experiencing pain. The client rates the pain as 2 out of 10 on the numeric 1 - 10 pain scale. Which prescription should the nurse administer? A) Acetaminophen B) Hydrocodone C) Ketorolac D) Morphine sulfate

Acetaminophen

Following a house fire, an adult male is admitted to the ER w/ partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands and his anterior legs. Using the Rule of Nines to assess the extent of the PT's burns, what percentage of burned body surface area should the nurse document? A) 50% B) 27% C) 9% D) 36%

B) 27%

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (SATA) A) A bedside commode is positioned near the bed B) A full pitcher of water is on the bedside table C) A low sodium diet tray was brought to the room D) The client is lying in a supine position in bed E) A saline lock is present in the right forearm

B) A full pitcher of water is on the bedside table D) The client is lying in a supine position in bed

The nurse who is working on a surgical unit receives change of shift report for a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse? A) Mastectomy 2 days ago with 50 mL bloody drainage noted in the Jackson-Pratt drain B) Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills C) Collapsed lung after a fall 8 hours ago with 100 mL blood in the chest tube collection container D) Gunshot wound 3 hours ago with dark drainage of 2 cm noted on the dressing

B) Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills

What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? A) Obtain adequate rest and sleep B) Reduce risk for infection C) Improve stress management skills D) Achieve satisfactory pain control

D) Achieve satisfactory pain control

A client with diabetes insipidus has an average urinary output of 500 mL of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor? A) White blood cell count B) Capillary glucose C) Urine specific gravity D) Serum sodium

D) Serum sodium

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? a. Explain that counseling will be provided to give her information about her cancer risk. b. Gather additional information about the client's family history for all types of cancer. c. Offer assurance that there are a variety of effective treatments for breast cancer. d. Provide information about survival rates for women who have this genetic mutation.

a. Explain that counseling will be provided to give her information about her cancer risk.

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client? A) Restrict oral fluid intake B) Avoid urinary catheterization C) Strain all urine D) Maintain contact isolation

B) Avoid urinary catheterization

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? A) Decrease in the appetite B) Weight of 227 pounds C) Dry mucosal membranes D) Body mass index (BMI) of 17

D) Body mass index (BMI) of 17

The wife of a newly-diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide? A) Compile a list of alternative medications that are effective in curing Parkinson's disease. B) Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease. C) Encourage the wife to ventilate her feelings about having a husband with Parkinson's disease. D) Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism.

D) Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism.

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time? A) Risk for infection. B) Impaired physical mobility. C) Self-care deficit D) Risk for impaired skin integrity.

A) Risk for infection.

The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching? A) A diet of healthy fruits, such as bananas and kiwis, are best for the child B) Only foiled balloons will be used for the child's birthday party C) Rubber-free toys such as wooden building blocks are good choices for the child D) An epinephrine auto-injector will be on hand to treat allergic reactions.

A) A diet of healthy fruits, such as bananas and kiwis, are best for the child

An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take? (SATA) A) Ask if the mother is experiencing any pain with urination. B) Encourage increased intake of high protein foods. C) Instruct the daughter to check her mother's temperature. D) Review the client's current food and medication allergies. E) Determine if the mother has recently experienced a fall.

A) Ask if the mother is experiencing any pain with urination. C) Instruct the daughter to check her mother's temperature. E) Determine if the mother has recently experienced a fall.

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? A) Ask the wife to stop and assess the client's swallowing reflex B) Give the wife a straw to help facilitate the client's drinking C) Assist the wife and carefully give the client small sips of water D) Obtain thickening powder before providing any more fluids

A) Ask the wife to stop and assess the client's swallowing reflex

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? (SATA) A) Report serum albumin and globulin levels B) Provide diet low in phosphorus C) Increase oral fluid intake to 1,500 mL daily D) Note signs of swelling and edema E) Monitor abdominal girth

A) Report serum albumin and globulin levels D) Note signs of swelling and edema E) Monitor abdominal girth

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement? A) Encourage family members to cook meals outdoors and bring the cooked food inside. B) Advise the client to replace cooked foods with a variety of different nutritional supplements. C) Assess the client's mucous membranes and report the findings to the healthcare provider D) Instruct the client to take an antiemetic before every meal to prevent excessive vomiting.

A) Encourage family members to cook meals outdoors and bring the cooked food inside.

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? A) Evaluate the newly hired UAP's level of competency by observing the UAP deliver care B) Assign the newly hired UAP to clients who require the least complex level of care C) Ask the most experienced UAP on the team with the newly hired UAP D) Review the UAP's skills checklist and experience with the person who hired the UAP

A) Evaluate the newly hired UAP's level of competency by observing the UAP deliver care

An adult male reports that he recently experience an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolo which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client? (SATA) A) Family health history B) Homosexual lifestyle C) History of hypertension D) Vegetarian diet E) Excessive aerobic exercises

A) Family health history C) History of hypertension

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problems should the nurse include in this client's plan of care? (SATA) A) Fluid volume excess B) Decreased cardiac output C) Altered peripheral tissue perfusion D) Fluid volume deficit, E) Fatigue

A) Fluid volume excess B) Decreased cardiac output C) Altered peripheral tissue perfusion E) Fatigue

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A) Hypertension B) Difficulty locating the uterine fundus C) Saturation of more than one pad per hour D) Excessive lochia

A) Hypertension

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A) Initiate intravenous fluids as prescribed B) Remove the catheter and apply direct pressure for 5 minutes C) Notify the healthcare provider of the need to reposition the catheter D) Secure the catheter using aseptic technique

A) Initiate intravenous fluids as prescribed

A female who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client? A) Is it possible that you will be in direct contact with the children at the school? B) Do you realize that you will be exposed to many different kind of germs? C) Are you aware that you do not have a fully functioning immune system? D) Have you considered that you are putting yourself at risk for developing infections?

A) Is it possible that you will be in direct contact with the children at the school?

A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include in the client's plan of care? (SATA) A) Monitor cardiac rhythm via telemetry. B) Report changes in pre-existing murmurs. C) Schedule rest periods between activities. D) Maintain record of fluid intake and output. E) Initiate contact transmission precautions.

A) Monitor cardiac rhythm via telemetry. B) Report changes in pre-existing murmurs. E) Initiate contact transmission precautions.

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (SATA) A) Natural whole almonds B) Cheddar cheese cubes C) Lightly salted potato chips D) Plain, air-popped popcorn E) Canned fruit in heavy syrup

A) Natural whole almonds D) Plain, air-popped popcorn

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider? A) Ortolani maneuver causing a click at the hip joint B) Babinski test that reveals fanning of toes C) Plumb line test indicates fetal position curvature D) Moro test precipitating a startle response

A) Ortolani maneuver causing a click at the hip joint

A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are temperature 99.6 F, heart rate 98 beats/minute, respirations 18 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement? A) Prepare for endotracheal intubation B) Place the client in a forward-leaning position C) Apply a non-rebreather mask at 100% oxygen D) Obtain a sputum sample for culture and sensitivity

A) Prepare for endotracheal intubation

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is BEST for the nurse to implement? A) Provide dolls and equipment to re-enact feelings associated with painful procedures B) Give the child syringes or hospital masks to play with at home prior to hospitalization. C) Provide a family tour of the preoperative unit one week before the surgery is scheduled. D) Include the child in play therapy with children who are hospitalized for similar surgery.

A) Provide dolls and equipment to re-enact feelings associated with painful procedures

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care? A) Teach technique for scanning the environment B) Encourage the use of corrective lenses during the day C) Alternate an eye patch from eye to eye every 2 hours D) Practice visual exercises that focus on a still object

A) Teach technique for scanning the environment

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. which response is best for the nurse to provide? A) Tell the client to discuss the medication side effects with the healthcare provider B) Inform the client that gradual tampering must be used to discontinue the medication C) Remind the client that feeling better is the therapeutic effect of the medication D) Tell the client that the medication's side effects will most likely dissipate over time

A) Tell the client to discuss the medication side effects with the healthcare provider

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse (SATA) A) Thirst and frequent requests for bathroom breaks B) Shaking that changes the child's handwriting legibility C) Bruises on both knees after the weekend D) Refuses to complete written homework assignments E) Sunburn with blisters on the face, arms, and hands

A) Thirst and frequent requests for bathroom breaks B) Shaking that changes the child's handwriting legibility E) Sunburn with blisters on the face, arms, and hands

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the PRIORITY nursing problem for this client? A) Anticipatory grieving B) Pain (acute) C) Anxiety D) Knowledge deficit

C) Anxiety

During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse? A) "It should be all right as long as you confine your skiing to the easier traits" B) "Go for it. Skiing should provide you with a terrific aerobic workout" C) "Cold weather may constrict your blood vessels raising your blood pressure" D) "Skiing might produce too much exertion. How about sledding?"

C) "Cold weather may constrict your blood vessels raising your blood pressure"

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? A) "I always shake the inhaler several times before I start" B) "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away" C) "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best" D) "I never use the inhaler unless I am feeling really short of breath"

B) "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away"

A client's morning assessment includes bounding peripheral pulses, weight gain of 2 lbs, pitting ankle edema, and moist crackles bilaterally. Which intervention is MOST important for the nurse to include in the client's plan of care? A) Restrict daily fluid intake to 1500 mL B) Administer prescribed diuretic. C) Maintain accurate intake and output. D) Weigh client every morning

B) Administer prescribed diuretic.

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is BEST for the nurse to implement? A) Refer the parents to the chaplain to provide grief counseling. B) Assure the parents that a terminal diagnosis was inevitable. C) Tell the parents that blaming each other will not change the situation. D) Explain to the parents that anger is a common response to grief.

B) Assure the parents that a terminal diagnosis was inevitable.

The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? A) Continued development of the brain lesion determines the child's outcome. B) Brain damage with CP is not progressive but does have a variable course. C) CP is one of the most common permanent physical disability in children. D) Severe motor dysfunction determines the extent of successful habilitation.

B) Brain damage with CP is not progressive but does have a variable course.

A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assess the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? A) Administer a nonsteroidal anti-inflammatory drug for pain. B) Check neurovascular status of the distal digits. C) Change the dressing if drainage increases. D) Position the arm in a sling for a discharge.

B) Check neurovascular status of the distal digits.

What might the nurse suggest to a client with fibrocystic breasts in an attempt to relieve her symptoms A) "Increase high-calcium foods in your diet" B) "Eat a low-carbohydrate, high-protein diet" C) "Eliminate caffeine from your diet" D) "Avoid vigorous physical exercise immediately after your menstrual period"

C) "Eliminate caffeine from your diet"

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement? A) Advise the UAP to document the last blood pressure obtained on the client's graphic sheet B) Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. C) Document why the blood pressure cannot be accurately measured at the present time. D) Estimate the blood pressure by assessing the pulse volume of the client's radial pulses

B) Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? A) Assess for altered sensorium. B) Determine type of chemical exposure. C) Obtain equipment for gastric lavage. D) Call poison control emergency department.

B) Determine type of chemical exposure

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include? A) Use a quick dart-like motion to inject into the dorsogluteal site B) Divide the medication into 2 injections with volumes under 1 mL C) Administer into the deltoid muscle while the parents holds the infant securely D) Select a 22 gauge 1.5 inch needle for intramuscular injection

B) Divide the medication into 2 injections with volumes under 1 mL

The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? A) Use soothing statements to facilitate cooperation B) Examine the genitalia as the last part of the total exam C) Allow the child to keep underpants on to examine the genitalia D) Work slowly and methodically so not to stress the child

B) Examine the genitalia as the last part of the total exam

The nurse is assessing a male client with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that the he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The healthcare provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? A) Hypotonic saline solution at 100 mL/hr until all edema disappears. B) Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmHg. C) Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves. D) Regular insulin drip to keep blood glucose around 100 mg/dL (5.55 mmol/L).

B) Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmHg

A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that "My favorite nurse is on duty now." Which response is BEST for the nurse to provide to this client's dichotomous tendency? A) Tomorrow I will talk to that nurse about how you were treated last night. B) I am happy that you are getting better and will be able to go home. C) I am glad you like me. Which nurse was acting aloof to you? D) What did the night nurse do that makes you think she is aloof?

B) I am happy that you are getting better and will be able to go home.

A client in menopause reports being lactose intolerant. She exercises 3 times a week, drinks wine 1 to 3 times a month, and drinks a cup of coffee daily. which instruction should the nurse provide to the client to reduce her risk of developing osteoporosis? A) Increase weekly exercise B) Increase calcium intake C) Decrease wine consumption D) Decrease coffee consumption

B) Increase calcium intake

A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement? A) Log roll and place adult disposable briefs B) Insert an indwelling urinary catheter C)Maintain traction while client uses the urinal D) Release traction so client can use bedpan

B) Insert an indwelling urinary catheter

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? A) Check your pulse rate every day. B) Report unusual bruising or bleeding C) Monitor your blood pressure regularly D) Elevate your feet if swelling occurs.

B) Report unusual bruising or bleeding

The nurse notes that an older client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take? A) Collect a sputum sample immediately. B) Request a consultant to confirm dysphagia. C) Offer the client additional clear liquids frequently. D) Encourage client to do deep breathing exercises daily.

B) Request a consultant to confirm dysphagia.

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A) Aerobic exercise B) Weight-bearing exercise C) Muscle stretching and toning D) Core strengthening

B) Weight-bearing exercise

A 15-year-old male client was recently diagnosed with the type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? A) Advise him to take his own food with him when going to fast food restaurants with his friends B) Encourage him to find activities to do with his friend that do not involve eating C) Assist him in identifying popular fast foods that are within his meal plan for diabetes D) Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet

C) Assist him in identifying popular fast foods that are within his meal plan for diabetes

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A) Chemotherapy B) Immunosuppressive therapy C) Blood transfusions D) Bone marrow transplantation

C) Blood transfusions

The mother of a 12-month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a lost of appetite. Which instruction should the nurse provide? A) Perform CPT only in the morning, but increase frequency when appetite improves B) Perform CPT after meals to increase appetite and improve food intake C) CPT should be performed more frequently, but at least an hour before meals D) Stop using CPT during the daytime until the child has regained an appetite.

C) CPT should be performed more frequently, but at least an hour before meals

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? (SATA) A) Weeping serosanguineous fluid from wounds B) Sloughing tissue around wound edges C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity E) Complaint of increased pain and pressure

C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity E) Complaint of increased pain and pressure

A nurse is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? A) Low-grade fever, headache, and malaise for the past 72 hours. B) One-inch bleeding laceration on the chin of a crying 5-year-old C) Chest discomfort one hour after consuming a large- spicy meal D) Unable to bear weight on the left foot, with swelling and bruising

C) Chest discomfort one hour after consuming a large- spicy meal

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? A) History of intravenous drug abuse B) Conversion of the client's PPD test from negative to positive C) Current diagnosis of hepatitis B D) Length of time of the exposure to tuberculosis

C) Current diagnosis of hepatitis B

The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms? A) Rigid board-like abdomen and elevated WBC count B) Dull, left lower cramping pain and low grade fever C) Diarrhea, abdominal pain, and weight loss D) Changes in bowel habits, blood in stool, and unexplained anemia

C) Diarrhea, abdominal pain, and weight loss

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol? A) Excessive eating, constipation, headache B) Nausea, vomiting, diaphoresis, anxiety, tremors C) Dilated pupils, tachycardia, elevated blood pressure, elation D) Mood lability, poor hand coordination, fever, drowsiness

C) Dilated pupils, tachycardia, elevated blood pressure, elation

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobaimain two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? A) Encourage the husband to bring the client to the clinic for a complete blood count B) Determine if the client is taking iron and folic acid supplements C) Explain that memory loss and confusion are common with Vitamin B12 deficiency D) Ask if the client is experiencing any changes in bowel habits.

C) Explain that memory loss and confusion are common with Vitamin B12 deficiency

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? A) Encourage the mother to breastfeed B) Wrap tightly in a warm blanket C) Obtain a capillary glucose level D) Feed 30 mL of 10% dextrose in water

C) Obtain a capillary glucose level

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every 2 hours. What additional action should the nurse instruct the UAP to take each time the client is turned? A) Empty the urinary drainage bag B) Assess the breath sounds C) Offer the client oral fluids D) Feed the client a snack

C) Offer the client oral fluids

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (SATA) A) Take out dentures and place in a labeled cup. B) Apply a body shroud. C) Place a small pillow under the head. D) Remove resuscitation equipment from the room. E) Gently close the eyes

C) Place a small pillow under the head. D) Remove resuscitation equipment from the room. E) Gently close the eyes

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? A) Remove pillows and soft toys from the crib at bedtime. B) Keep a bulb syringe accessible for use for an infant. C) Position the infant in a supine position while sleeping. D) Do not prop bottles for an infant during naps and bedtime.

C) Position the infant in a supine position while sleeping

A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? A) Teach the client about the side effects of the prescribed anti-infective drug B) Assess the last 24-hour oral and intravenous fluid intake and urine output C) Administer the initial dose of the anti-infective drug as prescribed D) Obtain a urine specimen for a prescribed culture and sensitivity test

D) Obtain a urine specimen for a prescribed culture and sensitivity test

Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client? A) Right-sided paralysis B) 2+ pitting edema of the feet C) Pallor D) Orthopnea

D) Orthopnea

The nurse working in the psychiatric clinic has a phone messages from several clients. Which call should the nurse return first? A) A young man with schizophrenia who wants to stop taking his medications B) The mother of a child who was involved in a physical fight at school today C) A client diagnosed with depression who is experiencing sexual dysfunction D) A family member of a client with dementia who has been missing for 5 hours.

D) A family member of a client with dementia who has been missing for 5 hours.

A client is admitted with a severe asthma attack. For the last 3 hours the client has experienced increasing shortness of breath. Arterial blood gas results are: pH 7.22; PaCO2 55 mmHg; HCO3 25 mEq/L (25 mmol/L). Which intervention should the nurse implement? A) Space care to provide periods of rest. B) Instruct client to purse lip breath. C) Position client for maximum comfort. D) Administer PRN dose of albuterol.

D) Administer PRN dose of albuterol.

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients? A) An older adult who is scheduled for foot amputation due to diabetes complications B) An older client who is one day postoperative with a colostomy for colon cancer C) An adult with alcoholism, cirrhosis, and hepatic encephalopathy D) An adult who is one day postoperative for a laparoscopic cholecystectomy

D) An adult who is one day postoperative for a laparoscopic cholecystectomy

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action? A) Determine why the UAP did not notify the nurse of the change in the client's condition B) Advise the UAP to stop providing care so the nurse can assess the client's condition C) Explain to the UAP that changes in a client's condition should be reported immediately D) Ask the UAP to position the client so the oral medication can be administered.

D) Ask the UAP to position the client so the oral medication can be administered.

A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? A) Distended, tortuous veins in the left hand B) Auscultation of a thrill on the left forearm C) The left radial pulse is 2+ bounding D) Assessment of a bruit on the left forearm

D) Assessment of a bruit on the left forearm

The nurse is caring for a client is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first? A) Irrigate the dialysis catheter B) Check the client's blood pressure and serum bicarbonate C) Change the client's position D) Continue to monitor intake and output with the next exchange

D) Continue to monitor intake and output with the next exchange

The nurse is caring for a client entering the second stage of labor. Which action should the nurse implement first? A) Prepare the client for spinal anesthesia B) Prepare the coach to accompany the client to delivery C) Empty the client's bladder using a straight catheter D) Convey to the client that birth is imminent

D) Convey to the client that birth is imminent

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider IMMEDIATELY? A) Facial numbness B) Right ear hearing loss C) Difficulty with balance D) Intensifying headache

D) Intensifying headache

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus, the client tells the nurse in a loud voice to leave the room. Which action should the nurse take? A) Encourage client to implement relaxation techniques B) Explain that insulin is a life-saving drug for the client C) Refer the client to the social worker for support therapy D) Leave the client's room and return later in the day

D) Leave the client's room and return later in the day

An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breath and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides a copy of the client's living will. Which action should the nurse take? A) Alert the nursing staff of the client's do not resuscitate status B) Facilitate a family meeting with the palliative care team C) Place a certified copy of the living will in the client's record D) Notify the healthcare provider of the client's wishes

D) Notify the healthcare provider of the client's wishes

A client with end-stage renal disease (ESRD) is refusing all treatment and requests that no life-saving measures be implemented. The healthcare provider refuses to write do-not-resuscitate instructions. Which action should the nurse take? A) Initiate a review of the situation by the hospital's ethics committee B) Remind the client that new treatments are being developed daily C) Facilitate a palliative care meeting with the client and healthcare provider D) Provide the healthcare provider with a copy of the client's bill of rights

D) Provide the healthcare provider with a copy of the client's bill of rights

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the IV line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? A) Replace the IV site with a smaller gauge. B) Apply soft bilateral wrist restraints C) Leave the lights on in the room at night D) Redress the abdominal incision

D) Redress the abdominal incision

A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over his chest and back. Which intervention should the nurse implement? A) Apply an anti-itch ointment over the rash area B) Instruct the client to avoid lying on his back C) Administer scheduled dose of glucocorticoid D) Replace the transfusion with normal saline

D) Replace the transfusion with normal saline

A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perineal pain after her last delivery. What action should the nurse implement? A) Use an analgesic spray to the perineal area to reduce pain. B) Apply an ice pack to the perineum for the first 24 hours. C) Teach the client how to practice Kegel exercises. D) Review the use of sitz bath equipment with the client.

D) Review the use of sitz bath equipment with the client.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understands the prescribed diet? A) Roast pork, fresh strawberries B) Pancakes, whole-grain cereals C) Baked potato with skin, raw carrots D) Roast turkey, canned vegetables

D) Roast turkey, canned vegetables

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A) White blood cell count of 12,000 mm3 B) Urine culture positive for MRSA C) Serum sodium of 145 mEq/L (145 mmol/L) D) Serum creatinine of 4.5 mg/dL

D) Serum creatinine of 4.5 mg/dL

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? A) AS the burn heals, the graft permanently attaches. B) Grafts are later removed by a debriding procedure. C) Grafting increases the risk for bacterial infections. D) The xenograft is taken from nonhuman sources.

D) The xenograft is taken from nonhuman sources.

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A) Case management and screening for clients with HIV B) Regional relocation center for earthquake victims C) Lead screening for children in low-income housing D) Vitamin supplements for high-risk pregnant women

D) Vitamin supplements for high-risk pregnant women