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Arterial blood gases (ABGs) reflect a pH of 7.28, PaCO2 of 30, and HCO3 of 18. To which client would these ABGs most likely belong? 1. Weight loss of 20% in past month 2. Highly anxious with a panic attack 3. Alzheimer's with recent overdose of acetylsalicylic acid 4. Post-op with gastric suction

To promote rapid diuresis in a client in acute pulmonary edema, which prescription should the nurse administer first? 1. Furosemide 40 mg IVP 2. Dopamine 15 mcg/kg/min 3. Hydrochlorothiazide 25 mg PO 4. Captopril 25 mg PO

What assessment data is the priority nursing concern in a client receiving prednisolone for the treatment of nephrotic syndrome? 1. Weight gain of 2 lbs (0.907 kg) in 24 hours 2. Temperature 99.6°F (37.5° C) 3. Blood glucose 116 mg/dL 4. Blood pressure 138/88

Which client should the nurse see first after receiving report on assigned clients? 1. Having dyspnea after surgery. 2. Needing an IV started for the administration of blood. 3. Crying with pain after back surgery. 4. Vomiting dark brown, granular material.

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

Which task would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

While reviewing the prescriptions written by a primary healthcare provider, the nurse notes that ibuprofen 30 mg by mouth every 6 hours is prescribed for a child weighing 6 kg. The drug information book states that the appropriate dosage range is 20-30 mg/kg/24 hours. What action should the nurse take? 1. Administer the ibuprofen at 30 mg by mouth every 6 hours. 2. Contact the nursing supervisor regarding the prescription. 3. Ask the pharmacist to calculate the appropriate dose. 4. Notify the primary healthcare provider.

A client diagnosed with confusion and dehydration is admitted to the medical unit. The RN is working with an LPN and an unlicensed assistive personnel (UAP). Which tasks would be best for the RN to assign to the LPN? 1. Insert an indwelling urinary catheter 2. Reinforce the teaching plan with the client's family 3. Maintain fluids at bedside 4. Assess I & O for adequate fluid replacement 5. Obtain daily weights

1,2

A home care nurse is completing an initial assessment on an elderly client living alone. What normal effects of aging would the nurse expect to find? 1. Loss of skin elasticity 2. Decline in sensory system 3. Decreased enjoyment of intimacy 4. Forgetfulness 5. Desire to remain at home

1,2

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? 1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70

1,2,3

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? 1. Evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering a client's blood pressure. 4. Some researchers believe that animals actually may retard the aging process among those who live alone. 5. Nursing home clients are more submissive after petting an animal.

1,2,3,4

A client has been admitted with a diagnosis of community-acquired pneumonia to the left lower lung lobe. What assessment findings by the nurse would validate this diagnosis? 1. Bronchial breath sounds over left lower lobe 2. Upper abdominal discomfort 3. Percussion reveals resonant sound over affected area 4. Tachypnea 5. Use of accessory muscles with breathing

1,2,4,5

What assessment data would a nurse expect to find in a client diagnosed with a severe episode of acute inflammatory bowel disease? 1. Dark yellow urine 2. Fever 3. Frequent, hard stools 4. Lower abdominal cramping 5. Tachycardia

1,2,4,5

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1,2,4,5,6

The nurse cares for a client after a gastroscopy examination. Which nursing interventions are appropriate post-procedure? 1. Maintain NPO status until the gag reflex returns. 2. Observe for hematemesis. 3. Monitor intake and output. 4. Assess bowel elimination. 5. Monitor respirations. 6. Connect to oxygen saturation monitor.

1,2,5,6

The nurse is assisting with a client who will receive electroconvulsive therapy (ECT). The anesthesiologist administers succinylcholine chloride intravenously. What adverse effects should the nurse monitor for post procedure? 1. Malignant hyperthermia 2. Hypokalemia 3. Apnea 4. Tetany 5. Arrhythmias

1,3,4,5

A client is receiving morphine 12.4 mg/hour as a continuous rate via a patient controlled analgesia (PCA) pump. How many mL/hour would the nurse calculate that the client is receiving? Round to the second decimal place. Use numbers and decimals only. Exhibit

1.24

The nurse is caring for a client who is to receive an antibiotic in 50 mL of D5W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round answer to the nearest whole number.

100

A child diagnosed with acute lymphocytic leukemia (ALL) is receiving vincristine sulfate during the induction phase of chemotherapy. What client side effect should the nurse report immediately to the primary healthcare provider? 1. Anemia 2. Paresthesia 3. Nosebleeds 4. Alopecia

The nurse has been assigned four clients. Who should the nurse see first? 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this immediate post-treatment period? 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2,3

Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation? 1. Keep the residual limb elevated on a pillow at all times 2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day 4. Keep head of bed elevated with knees up. 5. Apply anti-embolism stockings to the unaffected leg

2,3

A client diagnosed with new onset atrial fibrillation has been prescribed dabigatran. What should the nurse teach this client? 1. Place medication in a weekly pill organizer so that medication is not forgotten. 2. Do not take with clopidogrel. 3. Dabigatran decreases the risk of stroke associated with atrial fibrillation. 4. Take this medication with food. 5. aPTT and INR levels will be drawn monthly.

2,3,4

A client is admitted with abdominal pain, distention, fever, dehydration, (+) Cullen's sign and a rigid boardlike abdomen. Which interventions would help control the client's pain in the acute period? 1. Small frequent feedings 2. NG tube to low suction 3. Side-lying position with head elevated 4. Hydromorphone by PCA pump 5. IV isotonic solutions

2,3,4

A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? 1. Approach client from the right side. 2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea. 5. Assist client to turn, cough, and deep breathe every 2 hours. 6. Place client prone for 1 hour.

2,3,4

A nurse is helping a client to maintain normal voiding habits while recovering from a cesarean section. What methods should the nurse initiate? 1. Have the client recline slightly while using bedside commode. 2. Encourage the client to push over the pubic area with hands. 3. Suggest the client read or listen to music. 4. Pour warm water over the perineum. 5. Stay and talk with client while waiting for urge to void.

2,3,4

Who often performs the responsibilities of a case manager? 1. Physical therapist 2. Social worker 3. Dietitian nutritionist 4. Nurse 5. Unlicensed assistive personnel

2,4

After reinforcing dietary teaching to a client diagnosed with Crohn's Disease, the nurse recognizes client understanding when the client selects which low-residue foods? 1. Broccoli 2. Oatmeal 3. Green peas 4. Spaghetti 5. Cantaloupe 6. Raisins

2,4,5

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2,5

The nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. In what order should the nurse properly dispose of the implant? Put on gloves Pick up implant with tongs Place implant in lead lined container Call radiation department to take the implant out of the room

This is correct order

Place the steps in order that the nurse should take to administer a subcutaneous injection. Perform hand hygiene Apply gloves and locate the injection site Cleanse site with antiseptic swab Remove the needle cap by pulling it straight off Hold syringe and pinch the skin with nondominant hand Inject the needle and administer the medication Dispose the syringe in sharps container

This is the correct order

The primary healthcare provider prescribed diazepam 12.5 mg IM to a client. The pharmacy dispenses diazepam 5 mg/mL. How many mL will the nurse administer? Round answer using one decimal point.

2.5

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet 2 inches tall. Determine the client's BMI to the nearest tenth?

24.7

A nurse is assigned to care for a client with bipolar disorder in the manic phase. Which behavior by the client would require immediate intervention by the nurse? 1. Excessive involvement in a pleasurable activity 2. Suggestive, sexual remarks to the staff 3. Impulsive behavior 4. Euphoria with unusual energy

The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what? 1. An inappropriate desire for youthfulness and staying young. 2. The decision to never marry. 3. The lack of a sense of wholeness, purpose, and a life well lived. 4. The fear of experiencing a painful death.

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

A second nurse is verifying that a dose of insulin is correct based on the client's prescription. How many units of insulin has the nurse drawn up?Answer using numbers only.

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? 1. Alopecia 2. Arthritis of hands 3. Weight gain 4. Fever

Following amniotomy, what intervention should the nurse perform? 1. Administer oxygen to client. 2. Have client ambulate to promote labor. 3. Obtain temperature every 4 hours. 4. Monitor fetal heart rate.

What action is most important for the nurse to take when a client receiving a cephalosporin develops abdominal cramping and diarrhea? 1. Administer antidiarrheal medication. 2. Increase fluid intake. 3. Provide food with the medication. 4. Notify the healthcare provider.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.

Which medication should the nurse administer first after receiving the morning shift report? 1. Levothyroxine to the client with hypothyroidism and a thyroid stimulating hormone (TSH) level of 2.8 mU/L 2. Amlodipine to the client with hypertension and a blood pressure of 150/86 3. Regular insulin sliding scale dose to the client with diabetes and a 210 blood glucose level. 4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3

A client with an ischemic stroke was prescribed warfarin 5 mg daily by mouth 48 hours ago. At 0830 the international normalized ratio (INR) reading was 2.0. What action should the nurse take? 1. Administer warfarin. 2. Administer phytonadione. 3. Request the lab to run another INR. 4. Notify the primary healthcare provider about the INR level.

The nurse assessing clients in a pediatric clinic would refer which child for further assessment? 1. A 20 month old who only says "no." 2. A 1 year old who says three words 3. A 9 month old who says "dada" and "mama" 4. A 4 month old who laughs out loud

The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.

What is the priority nursing action for a pregnant client who has dilated to 6 centimeters while receiving an epidural? 1. Continuous monitoring of maternal blood pressure. 2. Frequent auscultation of the fetal heart rate. 3. Administer an IV fluid bolus of at least 500 mL. 4. Frequent monitoring of the maternal temperature.

Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client's blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day.

What signs/symptoms would the nurse expect to assess in a client diagnosed with exocrine pancreatic cancer? 1. Dark tea colored urine 2. Clay colored stools 3. Jaundice 4. Coffee ground emesis 5. Lower abdominal pain

1,2,3

What should the nurse check when assessing a client's balance? 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses

1,3,4

A hospitalized client has developed diabetes insipidus and is given desmopressin. The nurse is aware which laboratory result indicates an improvement in the client's condition? 1. White blood cells of 7,000 mm3 (7 x 10^9) 2. Urine specific gravity of 1.010 3. Hemoglobin of 22 g/dL (220 g/L) 4. Serum sodium of 148 mEq/L (148 mmol/L)

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

What is the primary electrolyte that the nurse should be aware to monitor for in a client who is receiving an insulin infusion? 1. Sodium 2. Potassium 3. Calcium 4. Phosphorus

A nurse notes late decelerations in the fetus of a client who is receiving oxytocin via IV infusion. What nursing interventions should the nurse perform? 1. Administer naloxone. 2. Place client in side-lying position. 3. Stop oxytocin. 4. Increase the rate of IV fluids 5. Notify primary health care provider. 6. Administer oxygen at 8 L/min per face mask.

2,3,4,5,6

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2,3,4,6

In which situations should the nurse notify the primary healthcare provider of a medication incident? 1. Every occurrence. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2,4

Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa? 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation

2,4,5

A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? 1. Emergency cesarean delivery 2. Immediate high forceps delivery 3. Equipment for immediate suctioning of the newborn 4. Administration of IV oxytocin

At what age does the nurse expect to see a child build a tower of 9 blocks? 1. One 2. Two 3. Three 4. Four

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Demonstrate post operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

3,4,5

An Orthodox Jewish client receives the following lunch tray. What is the nurse's priority action? Exhibit 1. Nothing, since this is a healthy and acceptable lunch. 2. Ask the client to eat the lunch so food is not wasted. 3. Remove the tossed salad so the client can eat the other foods provided. 4. Call dietary to immediately make a new tray for the client.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

The lactation consultant is preparing to make rounds on the breastfeeding clients on the Labor, Delivery, Recovery, Postpartum (LDRP). Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.

The nurse enters a client's room and finds the client masturbating. Which action by the nurse would be most appropriate for the nurse to take? 1. Ask the client to stop 2. Remain in the room until client has finished. 3. Document the activity in the client's chart. 4. Quietly leave the room

The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? 1. "Don't cry. Your family member would not want it this way." 2. "Things will be fine. You just need to give yourself some time." 3. "Try not to be upset in front of your family member." 4. "I'm so sorry. This must be very difficult for you."

The nurse is caring for a client prescribed ondansetron due to postoperative nausea. Which side effect is the nurse most worried about the client experiencing with administration of this medication? 1. Respiratory depression 2. Hyperglycemia 3. Malignant hypertension 4. Torsades de pointes

Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.

Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking

The nurse, caring for a client post motor vehicle accident who sustained multiple crushing injuries, suspects that the client may be developing disseminated intravascular coagulation (DIC). Which assessment findings by the nurse suggest that the client is developing this complication? 1. Chest pain 2. Frothy sputum 3. Intermittent claudication 4. Subcutaneous emphysema 5. Petechiae 6. Blood oozing from chest tube insertion site

5,6

A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. Client with an open chest wound that is beginning to show signs of tracheal deviation. Client with blunt trauma to the spine that is unable to move extremities. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. Client with traumatic amputations with agonal respirations.

This is the correct order

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Client one day post splenectomy. Client diagnosed with cancer who is crying and states, "I am not ready to die". Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk.

This is the correct order

In what order should the triage nurse send the following clients into the emergency department for treatment? Place in order from first to last. Client reporting severe left lower leg pain and swelling after driving a car for 12 hours. Client reporting right lower quadrant abdominal pain with nausea since early morning. Client reporting sore throat and fever. Client who ran out of blood pressure medication yesterday; BP 150/92. Client who has poison ivy, reporting intense itching.

This is the correct order

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurses best response? 1. This is a common side effect of antidepressant medications. Perhaps a different antidepressant would cause less side effects. 2. Excessive sweating can have many causes. 3. I think that you should report this side effect to your primary healthcare provider. 4. This symptom should go away within a few days.

The nurse is discharging the client after removing sutures from an abdominal wound. Which instructions should the nurse give the client at the time of discharge to reduce the risk of complications? 1. inspect the wound daily for any changes 2. Resume normal activities when you go home. 3. Keep the incision covered at all times. 4. Follow up with primary healthcare provider when scheduled.

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1,2,3

The nurse is reinforcing teaching to a group of parents about transmission of the chickenpox virus and the importance of vaccination. Which modes of transmission for chickenpox should be included in the discussion? 1. Direct contact 2. Indirect contact 3. Airborne 4. Droplet 5. Common vehicle

1,2,3

What potential contributing factors for stress urinary incontinence should a nurse assess for in an elderly female client? 1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births 4. Spinal cord injury 5. Dementia

1,2,3

A client is admitted with a diagnosis of disorganized schizophrenia. What characteristic should the nurse anticipate being manifested? 1. Evidence of loose associations 2. Use of neologisms and clang associations 3. Unpredictable or inappropriate emotional responses 4. Presence of stupor or presence of waxy flexibility 5. Suspiciousness and delusions of persecution 6. Flat or inappropriate affect

1,2,3,6

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis? 1. Oxygen 2. Clopidogrel 3. Propranolol 4. Vitamin K 5. Lactulose

1,3,4,5

The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include? 1. Use moisturizer daily on dry skin. 2. Massage reddened skin areas. 3. Prevent shearing by maintaining the head of bed at 45 degrees or higher. 4. Place rubber ring (donut) under client's sacral area. 5. Position client at 30 degree tilt when placed on side.

1,5

The nurse is caring for a client receiving peritoneal dialysis. Place the steps for peritoneal dialysis in the correct order. Warm dialysate Access Tenckhoff catheter Begin dwell time Complete exchange Assess effluent

This is the correct order

After a heart catheterization a client reports severe foot pain on the side of the femoral insertion site. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous fluids. 4. Notify the primary healthcare provider.

What nursing interventions should the nurse initiate in a client who experiences sundowning? 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.

1,3,4,6

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? 1. Blood pressure 102/68 2. Glucose 118 mg/dL 3. UOP 440 mL over previous 8 hour shift. 4. Heart rate 56/min

What information should the nurse include in teaching an oncology client the purpose of taking epoetin? 1. Emergency treatment of anemia. 2. Improves quality of life. 3. Used for the prevention of pure red cell aplasia (PRCA). 4. Decreases the need for transfusion.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? 1. Pancytopenia 2. Leukocytosis 3. Erythema 4. Fever 5. Fatigue

1,3,5

A long-term care nurse is planning care for a newly admitted client diagnosed with alzheimer's disease. What should the nurse include in the plan of care? 1. Assess client's ability to perform self care. 2. Educate nursing staff to help client in all activities of daily living. 3. Separate tasks into small manageable steps. 4. Relieve family members of stress by advising them to visit 1 time per week. 5. Have nursing staff spend time talking and listening to client.

1,3,5

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? 1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby 5. Allows baby to cry vigorously for 15 minutes

1,2,3,4

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? 1. Furosemide 40 mg PO q.d. 2. Lisinopril 20.0 mg PO daily 3. Start MgSO4 at 3g/hr IV 4. Risperidone .5mg PO daily 5. Dexlansoprazole 30 mg PO daily

1,2,3,4

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room

1,2,3,5

An elderly client is being discharged home on warfarin following treatment for a deep vein thrombosis. While reviewing discharge instructions, the client asks the nurse if the newly ordered medication will interfere with herbal supplements taken at home. After reviewing all meds taken at home, the nurse knows the client will need to discontinue which supplements? 1. saw palmetto 2. St. John's wort 3. garlic tablets 4. echinacea 5. ginkgo biloba

1,2,3,5

The nurse is planning care for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). What should the nurse recognize as the child's likely view of this illness in order to properly plan care? 1. Punishment 2. Disturbance to body image 3. Rejection from parents 4. Change in routine with friends

What action by the nurse is most helpful when responding to a bomb threat phone call? 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others.

In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? 1. Dose rate. 2. Organs exposed. 3. Type of tumor being treated. 4. Presence of metastatic disease. 5. Type of radiation.

1,2,5

A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? 1. Initiate droplet precaution. 2. Place client under mist tent with low humidity. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. 5. Keep NPO.

1,3,4

A nurse is caring for a client who has been prescribed prednisone. What education should the nurse provide to the client? 1. Avoid crossing legs. 2. Eat a low calcium diet. 3. Take prednisone with food. 4. Taper prednisone dose prior to completion. 5. Instruct the client to use arm rests when rising from a chair.

1,3,4,5

Which assessments will provide the nurse with the most information regarding a client's neurologic function? 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

1,5

What nursing interventions are appropriate to prevent respiratory acidosis? 1. Deep breathing exercises 2. Assessing the pulse ox every 4 hours 3. Incentive spirometry every 2 hours 4. Elevate the head of bed 5. Administration of oxygen 6. Relaxation techniques

1,3,4

A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection. Thermal burns covering 30% of body surface area (BSA) 2 days ago Total hip prosthetic device placement 3 days ago Laparoscopic exploration of right knee 2 days ago Indwelling foley catheter inserted the previous day

This is the correct order

In what order should the triage nurse send the following clients into the emergency department for treatment? Place in order from first to last. Client with a respiratory rate of 28/min and end-expiratory wheezes on auscultation. Client reporting continuing angina after taking three doses of nitroglycerin. Client who has soaked a towel with blood from a thigh laceration. Client with a BP of 92/52. Client with right sided hemiparesis and a BP of 150/88.

This is the correct order

A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Which of the following RNs should not be assigned to this baby? 1. A nurse just back from maternity leave. 2. A nurse who is 10 weeks pregnant. 3. A nurse who is breastfeeding her 4 month old. 4. A nurse who is on hormone replacement therapy.

The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number.

A hospitalized client using a K-pad on an injured muscle reports the pad is not warming up. What should be the nurse's initial action? 1. Unplug unit and plug into another wall outlet. 2. Check temperature setting on the heating unit. 3. Call maintenance to repair unit immediately. 4. Increase temperature on unit till pad heats up.

What nursing intervention takes priority for the client one day postoperative bowel resection reporting pain of a 6 on a 0 to 10 pain scale? 1. Assist the client in changing positions. 2. Use a distraction technique. 3. Administer the prescribed analgesic. 4. Encourage the client to walk.

What should the nurse teach a client who has been prescribed sertraline 100 mg PO daily? 1. Kidney function must be monitored regularly 2. Decrease the dose of the prescribed MAO inhibitor 3. Do not stop taking medication abruptly 4. Expect weight loss

Four clients arrive at the emergency department. Which client should the nurse triage as the highest priority for care? 1. Adult with severe upper gastric pain. 2. Child with stridor and excessive drooling. 3. Adult with an open fracture to the right radius. 4. Child with fever of 103ºF (39.44 °C) and blood streaked sputum.

A client arrives at the emergency room with active gastrointestinal bleeding. What is the most important nursing action? 1. Treat the cause of the bleeding. 2. Record the amount of blood loss. 3. Initiate an intravenous access line. 4. Prepare client for stat endoscopy.

A client makes an initial visit to the prenatal clinic, informing nurse the probably date of conception was May 15th. The first day of the last menstrual cycle was on May 1st. Using Naegele's rule, the nurse determines the client's due date should be when? 1. February 22nd 2. August 8th 3. February 8th 4. August 22nd

The homecare nurse is visiting a newly diagnosed diabetic being treated for a small left foot wound. What is the nurse's priority assessment on this first home visit? 1. Determine stage and drainage of foot wound. 2. Assess the client's ability to prepare and administer insulin. 3. Check home environment for potential hazards. 4. Assess client's knowledge of signs of hypoglycemia.

The nurse is caring for a female client who is at risk for renal failure. The nurse has completed the initial assessment of the most recent lab results so that any concerns can be reported to the primary healthcare provider. Which assessment finding warrants further action? 1. Hemoglobin of 12 g/dl (120 g/L) 2. Hematocrit of 38% (0.38) 3. Potassium levels of 5.2mEq/L (5.2 mmol/L) 4. BUN of 15 mg/dl. (5.35 mmol/L)

What is the priority electrolyte imbalance for the nurse to monitor when caring for a client post op thyroidectomy? 1. Hypercalcemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypomagnesemia

What turning method should the nurse use to turn a client who has a spinal injury? 1. Lateral transfer 2. Slide sheet procedure 3. Logrolling 4. Mechanical lift transfer

While completing the admission history on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? 1. "You can come to visit anytime you want to." 2. "Would you like to see the room and facilities?" 3. "Let's find a quiet place to sit and talk awhile." 4. "You did the best you could in this situation."

An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

The nurse is caring for a client diagnosed with pneumonia. The primary healthcare provider has prescribed erythromycin ER. What teaching points should the nurse plan to teach the client regarding this medication? 1. Crush the medication if unable to swallow capsule. 2. Take erythromycin 1 hour after eating. 3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice. 5. Keep capsules in bathroom cabinet.

3,4

What electrolyte imbalance should the nurse monitor for in a client diagnosed with hyperosmolar hyperglycemic state (HHS)? 1. Hypocalcemia 2. Hypermagnesemia 3. Hyperkalemia 4. Hyponatremia

What should the nurse include when teaching a client diagnosed with Grave's disease who is scheduled to receive radioactive iodine? 1. Stay 6 feet from people for 2 weeks. 2. This medication is given intravenously as a one-time dose. 3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant. 5. Radioactive iodine is absorbed by the parathyroid glands.

3,4

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Clean client's halo fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

3,5,6

A new nurse is preparing an injection from an ampule. What action by the new nurse would require the precepting nurse to intervene? 1. Snaps the neck of the ampule gently towards the body. 2. Uses a filter needle when drawing up the ampule contents. 3. Folds gauze around the ampule neck before snapping open. 4. Avoids touching edges of the ampule when inserting needle.

The nurse is providing prenatal education for a couple expecting a first child. The expectant mother asks about fetal movements. What is the best explanation by the nurse? 1. "You should feel activity between weeks 16 to 20." 2. "The fetus is too small to feel any movements." 3. "Maybe around the end of the 1st trimester." 4. "It is different for each individual woman."

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB

1,2,3

A petite female client presents to the clinic with symptoms of back pain and states, "I think I am getting shorter." Which information would be appropriate for the nurse to provide? 1. Spend time in the sunlight. 2. Wear low heeled, nonslip sole shoes. 3. Walk at least 30 minutes most days. 4. Include yogurt and cheese in diet. 5. Take regularly scheduled prescribed corticosteroids.

1,2,3,4

A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider? 1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 3. Temperature of 101.2 degrees F (38.4 degrees C). 4. Increase of 5 mm Hg in systolic BP from baseline. 5. Sodium level of 130 mEq/L (130 mmol/L).

1,2,5

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

1,3,4,5

An elderly client is admitted to the floor with vomiting and diarrhea for three days. The client is receiving IV fluids at 200 mL/hr via pump. What would be the priority nursing action? 1. Obtaining Intake and Output 2. Frequent lung assessments 3. Vital signs every shift 4. Monitoring the IV site for infiltration

The telemetry unit nurse is assessing a newly admitted client following a fall at home. The client has been diagnosed with a left sided cerebrovascular accident (CVA), including aphasia, and a sprained wrist. What is the most effective method the nurse could use to assess the client's pain? 1. Monitor vital signs for elevations. 2. Observe client's non verbal behaviors. 3. Assess sleeping position client chooses. 4. Ask client to point to the pain rating scale.

A client has returned to the unit following an upper gastrointestinal series (Upper GI). What is the nurse's priority action? 1. Keep client NPO until the gag reflex returns. 2. Perform an immediate cleansing enema. 3. Administer 30 mLs milk of magnesia orally. 4. Monitor vital signs every ten minutes until stable.

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

During day shift, staff notifies the nurse that an elderly client seems slightly confused and has become incontinent. Upon assessing the client, the nurse notes an increased pulse with blood pressure lower than normal. What action by the nurse takes priority? 1. Call primary healthcare provider stat. 2. Notify family that client is confused. 3. Have staff collect a urine specimen. 4. Apply oxygen at 2/L via nasal cannula.

When preparing an intramuscular injection for a neonate, which needle should a nurse select? 1. 18 G, 7/8 inch 2. 21 G, 1 inch 3. 25 G, 5/8 inch 4. 25 G, 1.5 inch

Which task would be appropriate for the charge nurse to assign to a LPN/VN? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a PICC line that a client accidentally pulled out.

A client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client? 1. The nurse with a history of roseola. 2. The unlincesed assitive personnel (UAP) with no history of roseola. 3. The UAP with a history of chicken pox. 4. The LPN/VN with no history of chicken pox.

The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions? 1. Fear of unknown 2. Loss of daily routine 3. Body image disturbance 4. Separation anxiety

Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning.

1,4

A pregnant client who had been on a magnesium drip for severe pregnancy induced hypertension (PIH) has had an emergency cesarean section at 35 weeks. The nursery nurse should anticipate what findings in the newborn related to the magnesium therapy? 1. Hypotension 2. Hypoglycemia 3. Hyperreflexia 4. Flaccid muscle tone 5. Respiratory depression

1,4,5

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket

1,4,5

The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure? 1. Fowler's 2. Right side 3. Left side 4. Prone

The nurse is checking a 2 month old's developmental status. What finding would be of concern to the nurse? 1. Not able to hold head steady. 2. Does not bring hands to mouth. 3. Not able to roll over in either direction. 4. Does not push down with legs when feet are placed on a hard surface.

What does a non-stress test tell the nurse about a pregnant client? 1. That the baby is going to be a boy or girl 2. The baby is doing well and the placenta is providing enough oxygen at this time 3. That the baby's heart is healthy and there are no birth defects 4. That the mother is strong enough to undergo vaginal delivery

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea

A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.

A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? 1. Diminished colonic motility 2. Esophageal hemorrhage 3. Aspiration pneumonia 4. Stress ulcers

A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

What foods should the nurse inform the client to avoid for three days prior to a guaiac test? 1. Chicken 2. Carrots 3. Apple 4. Raw broccoli 5. Steak 6. Turnip greens

4,5,6

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test? 1. Alanine aminotransferase (ALT) 2. Serum glucose 3. Serum creatinine 4. Serum electrolytes

The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem? 1. Temperature 101 degrees F (38.3 degrees C) 2. Hot, dry skin 3. Profuse sweating 4. Headache

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? 1. Anger 2. Acceptance 3. Bargaining 4. Depression

The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3,4

A client has been prescribed a decongestant. The nurse identifies that the client has a diagnosis of glaucoma. Which nursing intervention would the nurse implement after identifying the client's diagnosis of glaucoma? 1. Administer the decongestant. 2. Reassess the client in 4 hours. 3. Identify when the client was diagnosed with glaucoma. 4. Notify the primary healthcare provider regarding the glaucoma diagnosis.

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? 1. "The medication permits safe breastfeeding after delivery." 2. "It protects you against other infections during pregnancy." 3. "This drug prevents transmission of HIV to your partner." 4. "ZDV decreases the chance the baby will contract HIV."

The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time? 1. Fluticasone 2. Salmeterol 3. Theophylline 4. Albuterol 5. Levalbuterol

4,5

A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant? 1. Ventricular fibrillation 2. Ventricular tachycardia 3. 2nd degree AV block 4. Atrial fibrillation

The home health nurse is assessing a client whose spouse died in a motor vehicle accident 6 months ago. The client says, "I feel all alone now". Which response by the nurse is therapeutic? 1. "You are feeling all alone." 2. "Why do you say you are lonely?" 3. "Your feelings of loneliness will decrease." 4. "I know other people who lost someone feel this way."

What is the best method for the nurse to verify correct nasogastric (NG) tube placement after insertion? 1. X-ray of the upper GI 2. Gastric aspiration and pH testing 3. Auscultation of air instilled into the stomach 4. Visualization of the tube markings

A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regarding? 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia

1,2,3

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

1,2,5,6

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1,2,6

A nurse is planning care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include in this plan of care? 1. Piggy back oxytocin into main IV fluid. 2. Monitor for early decelerations. 3. Discontinue if contractions last longer than 90 seconds. 4. Maintain one on one care. 5. Check fetal heart tones hourly.

1,3,4

The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats

1,3,4

Which clients should the nurse recommend receive the human papillomavirus (HPV) vaccine? 1. Twelve year old male. 2. Nine year old female. 3. Twenty-five year old bisexual male. 4. Twenty-two year old female with compromised immune system. 5. Twenty-six year old male who has not received the HPV vaccine.

1,3,4

The nurse is caring for a client that requires lifting. What techniques should the nurse utilize to prevent injury to self and potentially the client? 1. Tighten stomach muscles. 2. Keep the knees straight. 3. Keep weight to be lifted close to body. 4. Bend at the waist. 5. Avoid twisting the body.

1,3,5

Which cranial nerves should the nurse assess in a client diagnosed with Guillain-Barre' Syndrome? 1. Vagus 2. Olfactory 3. Vestibulocochlear 4. Facial 5. Trigeminal 6. Oculomotor

1,4,5,6

Over which locations does the nurse auscultate breath sounds? 1. Trachea and lateral areas of thoracic cage 2. Anterior and posterior aspects of all lung fields 3. The mid-section as well as the lateral section of the lungs 4. The mid-clavicular to mid-axillary lines comparing side to side

The nurse is preparing to give a client's prescribed levothyroxine dose. How many tablets will the nurse give to the client? Answer with numbers only. Exhibit

Which client should the nurse assign to a room closest to the nurse's station? 1. A multigravida admitted with a new diagnosis of gestational diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemic control

The nurse is preparing to administer Sunday's 1600 medications to a client. How many mg of Warfarin should the nurse administer? Answer using numbers only. Exhibit

The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? 1. Assisting with turn, cough, and deep breathing (TCDB) 2. Elevating the head of the bed to 30 degrees. 3. Measuring urinary output every hour. 4. Turning off room lights.

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? 1. Cover the pustules to prevent drainage. 2. Implement contact precautions immediately. 3. Instruct the client on the importance of hand hygiene. 4. Inform the client to wear a mask when ambulating in the hall. 5. Instruct visitors to wash hands before entering the client's room.

1,2,3,5

What foods should the nurse teach a client who has been diagnosed with iron deficiency anemia to increase in the diet? 1. Chickpeas 2. Milk 3. Oysters 4. Raisins 5. Spinach 6. Tuna

1,3,4,5,6

A nurse is taking care of a client with major partial thickness burns. Tobramycin 125mg IVPB has been prescribed. What is the priority lab assessment prior to administering this medication? 1. Creatinine 2. Potassium 3. Magnesium 4. Blood urea nitrogen

The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure

3,5

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What information should the nurse provide? 1. Limit alcohol intake when out in cold weather. 2. Dress in several layers of tight fitting clothing. 3. Eat well-balanced meals. 4. Synthetic clothes absorb moisture and become wet quickly. 5. Wear a wool headband over the ears. 6. Wear several pairs of socks.

3,5

A client admitted with a diagnosis of end stage kidney disease (ESKD) has been prescribed a diet containing no more than 1 gram of phosphate per day. Which food item, if found on the client's meal tray should be removed by the nurse? 1. Skinless chicken breast 2. Green beans 3. Asparagus 4. Ice cream

A client returns from post anesthesia care unit (PACU) following a mastectomy with a Jackson-Pratt drain in place. What action by the nurse is important? 1. Empty drain every eight hours. 2. Irrigate drain with NS every shift. 3. Drape tubing above breast incision. 4. Empty and compress bulb when 2/3 full.

The parents of a child hospitalized with cystic fibrosis have been given discharge instructions. The nurse knows that teaching has been successful when the parents make what statement? 1. "Our child will need to have a gluten free diet." 2. "The enzymes should be given at bedtime daily." 3. "Salt needs to be decreased in our child's diet." 4. "We need to prepare high calorie, high fat meals."

What discharge instructions should the nurse provide to the parents of a child diagnosed with sickle cell anemia? 1. Provide high-calorie, low protein diet. 2. Inheritance is by autosomal dominate genes. 3. Restrict all activities for 3 months. 4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.

4,5

A client weighing 140 pounds (63.64 kg) has been admitted to the telemetry unit with a diagnosis of Class III pulmonary hypertension. The primary healthcare provider prescribes digoxin. How many micrograms should the nurse administer now? Round to the whole number. Exhibit

477

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.

Which action would the nurse need to perform to increase stability while initiating a client transfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly.

The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed penicillin 100,000 units IM. The drug label reads penicillin 300,000 units/mL. The nurse would administer how many mL of this medication? Round answer using two decimal points.

0.33

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1,2

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1,3,4,6

A client has been admitted with a diagnosis of pneumocystis carinii pneumonia (PCP). What initial assessment findings would the nurse expect? (Select All That Apply). 1. Fever 2. Night sweats 3. Hemoptysis 4. Dry cough 5. Dyspnea

1,4,5

A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."

A concerned mother is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

A psychiatric nurse is completing an assessment on an elderly client being started on a tricyclic antidepressant. The nurse is aware the most crucial aspect of this assessment is evaluating what body system? 1. Endocrine 2. Nervous 3. Circulatory 4. Digestive

A young adult client frequently engages in high risk behaviors, including driving at high speeds, using alcohol in excess, and engaging in high risk sexual behaviors. Which problem is priority for the nurse to assess? 1. Antisocial personality traits causing the disregard for life. 2. Impaired judgment caused by arrested psychological maturation. 3. Unconscious suicidal thoughts. 4. Unhealthy grieving.

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? 1. Has slight head lag when pulled to sitting position. 2. Walks holding onto furniture. 3. Able to sit, leaning forward on both hands. 4. Has neat pincer grasp.

During the hospital discharge instructions a client asks the nurse, "What do you think I should do about my husband's smoking?" Which statement by the nurse is appropriate? 1. "Why are you asking me for advice?" 2. "I think you should talk to your husband." 3. "What do you think you should do?" 4. "You need to support him through his addiction."

Which finding would the nurse expect to see in a client diagnosed with pneumocystis carinii pneumonia (PCP)? 1. Hemoptysis 2. Fever 3. Dyspnea 4. CD4 count of 500 cells/cubic millimeter 5. Wheezing

2,3,5

A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first? 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.

The nurse is caring for a client post hysterectomy. Based on data obtained from the nurse's notes, what should be the nurse's initial response? Exhibit 1. Retake the vital signs. 2. Administer the ordered dopamine to maintain a blood pressure of 110 systolic. 3. Increase the IV rate of the lactated ringer's solution. 4. Raise the head of the bed to 30 degrees.

The nurse is caring for a preoperative client who received intravenous lorazepam 5 minutes ago and is now requesting to void. What is the appropriate nursing action? 1. Ask the unlicensed assistive personnel to assist the client to the bathroom. 2. Insert a indwelling urinary catheter since the client is going to surgery. 3. Place the client on a bedpan. 4. Allow the client to go to the bathroom.

A client is prescribed 2 grams of levodopa daily. Available forms of this drug include tablets of 500 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding

A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"

During a disaster, four clients arrive at the emergency department (ED). Which client should the nurse assess first? 1. Confused client wondering around ED. 2. Client with a compound fracture. 3. Client having agonal respirations. 4. Client with sucking chest wound.

Immediately following the birth of an infant, what is the nurse's priority action when caring for the newborn? 1. Examine the infant and take a set of vitals. 2. Confirm identification and apply arm band. 3. Instill silver nitrate solution into both eyes. 4. Dry infant and place in warm environment.

Labetalol has been prescribed for a client in the emergency room. Prior to administering this medication, what assessment should the nurse perform? 1. Listen to the client's breath sounds. 2. Check the client's temperature. 3. Monitor for peripheral edema. 4. Auscultate the apical pulse rate.

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.

The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Slightly swollen eyelid 2. Slight discomfort of the eye 3. "Bloodshot" appearance of the eye 4. Extreme pain in the eye

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

The nurse receives the morning lab results of four clients during the change of shift report. Which client should the nurse assess first? 1. Vomiting and diarrhea with a potassium 3.3 mEq/L (3.3 mmol/L). 2. One day post-operative hip replacement with a Hct 30% (0.30) / Hgb 10 g/dL (100 g/L). 3. Pneumonia with a White Blood Cell (WBC) count of 12,000/mm3 (12 x 10^9/L). 4. Diabetes with a Fasting Blood Sugar (FBS) of 40 mg/dL (2.2 mmol/L).

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main priority following surgery? 1. Obtain vital signs every four hours. 2. Assess the need for pain medication. 3. Tally intake and output every eight hours. 4. Auscultate lung sounds every four hours.

Which client in the emergency department should the nurse identify as being the highest priority? 1. Client with emphysema reporting shortness of breath. 2. Client with a cut on the left calf with moderate bleeding. 3. Client with onset of confusion 1 hour prior to arrival. 4. Client with facial swelling and rash after taking azithromycin.

Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins

5,6

The nurse is completing a focused assessment on a client post coronary artery bypass surgery (CABG). What finding warrants immediate attention by the nurse? 1. Central venous pressure (CVP) 6 mmHg 2. Mediastinal chest tube drainage of 70 mL in 1 hour 3. Incisional pain rated 9/10 4. Pulsus paradoxus

A client has been prescribed sodium polystyrene sulfonate 30 grams rectally every 6h times 2. Which laboratory value would indicate that the prescribed sodium polystyrene sulfonate has been effective? 1. Potassium 4.8 mEq/L (4.8 mmol/L) 2. Sodium 148 mEq/L (148 mmol/L) 3. Calcium 8.9 mg/dL (2.2207 mmol/L) 4. Magnesium 1.2 mEq (0.6 mmol/L)

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

1,3,4,5

A nurse is planning to discuss steps that senior citizens can take to keep the brain healthy. What should the nurse include? 1. Memorize poetry. 2. Eat foods low in Omega 3, fatty acids. 3. Brush teeth with nondominant hand. 4. Do crossword puzzles. 5. Learn a new language. 6. Volunteer.

1,3,4,5,6

Which client would be appropriate for the RN to assign to the LPN? 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

1,3,5

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? 1. Weigh QD 2. IV of Normal Saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

1,4

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education has been successful when a nurse selects which set of ABGs as metabolic acidosis? 1. pH - 7.32, PaCO2 - 48, HCO3 - 23 2. pH - 7.29, PaCO2 - 42, HCO3 - 19 3. pH - 7.5, PaCO2 - 30, HCO3 - 22 4. pH - 7.35, PaCO2 - 35, HCO3 - 26

An elderly client returns to a surgical room from the post anesthesia care unit (PACU) following an open reduction and fixation of a fractured ankle. Which nursing assessment of the client takes priority? 1. Level of consciousness 2. Complete vital signs 3. Surgical dressing 4. Pedal pulses

An occupational health nurse is reviewing the current medications of a client who has recently been prescribed propranolol for hypertension. Which current medication taken with propranolol by the client should be of concern to the nurse? 1. Cyanocobalamin 2. Melatonin 3. Cetirizine 4. Esomeprazole

The nurse has been assigned four clients. Who should the nurse see first? You answered this question Incorrectly 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

The nurse is providing discharge dietary instructions to a client diagnosed with full thickness burns to the right hand. To promote tissue healing, which food examples should the nurse provide to the client? 1. Pasta 2. Oranges 3. Brown rice 4. Chicken breast 5. Electrolyte drink

2,4

A client with psychosis, tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."

After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old who is 5 hours postop appendectomy. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a tracheostomy admitted for urinary tract infection (UTI).

The nurse is assigned to bathe a client diagnosed with dementia. Which nursing intervention should the nurse implement? 1. Increase the volume of the television. 2. Finish the bath as soon as possible. 3. Clean the face and hair at the end of the bath. 4. Delegate another nurse to distract the client.

The nurse is caring for a diabetic client. The client's glucose level at 0700 is 265. What is the nurse's best action? Exhibit 1. Hold the NPH and regular insulin 2. Give 8 units of regular insulin and hold the NPH 3. Give the NPH and 4 units of regular insulin 4. Give 40 units of NPH and hold the regular insulin

The nurse is evaluating the outcomes of nursing interventions for the client on the long-term care unit. The nurse has determined that the goal was partially met. What should the first nursing action be at this point to maintain quality of care? 1. Identify a new goal for the client since this one has not been achieved. 2. Consider new nursing interventions for achievement of the goal if the condition still warrants it. 3. Determine that the nursing interventions were performed as planned. 4. Allow more time for achievement of the goal.

The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? 1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse.

Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water-seal system? 1. Have client hold breath 2. Administer oxygen 3. Place the tubing coming from the client into sterile water 4. Raise the head of the bed

Which task would be appropriate for the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse to assign to an LPN/VN? 1. Administering IV pain medication to a client three days postopertive cesarean section. 2. Drawing a trough vancomycin level on a client 3 days postpartum with bilaterial mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Drawing routine admission labs on a client admitted in final stages of labor.

A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? Exhibit 1. Metabolic acidosis 2. Compensated metabolic alkalosis 3. Respiratory acidosis 4. Compensated respiratory alkalosis

A client is brought into the emergency department (ED) with nausea, vomiting and diarrhea after eating chicken at a picnic. The nurse suspects that this client has most likely contracted which infection? 1. Shigella 2. Escherichia coli 3. Clostridium Difficile 4. Salmonella

The nurse instructs a client taking isoniazid for the treatment of tuberculosis (TB) regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon with crackers. 4. Pear salad with lettuce.

The primary healthcare provider prescribes: Ceftriaxone sodium 50 mg/kg intramuscular now. The client weighs 22 pounds (10 kg). According to the manufacturer's instructions, the concentration is 100 mg/mL. How many milliliters (mL) should the nurse administer? Provide your answer using numbers and decimal points only. Do NOT include words. (Round to the nearest tenth)

A client who is 20 weeks pregnant and diagnosed with pelvic inflammatory disease is given a prescription for metronidazole. What should the nurse inform the client to avoid in order to prevent an interaction with metronidazole? 1. Furosemide 2. Alcohol 3. Doxycycline 4. St. John's Wort

A nurse asked the charge nurse on the psychiatric unit, "Why did you ask that client to explain the meaning of 'It's raining cats and dogs?'" What is the charge nurse's best response? 1. "I was attempting to get the client to admit to being afraid of cats and dogs." 2. "I am assessing the concreteness of the client's form of thought." 3. "Phrases like this one will help the client improve their abstract thinking ability." 4. "Concrete thinking is a higher form of thinking and means that the client's form of thought is improving."

The following clients arrive to the emergency department (ED) at the same time. The triage nurse gives priority to which client? 1. A client with a possible fracture of the tibia 45 minutes ago. 2. A client with left hemiparesis and aphasia beginning 1 hour ago. 3. A client smelling of alcohol and reporting of severe abdominal pain. 4. A client involved in a motor vehicle accident (MVA) with a possible fractured pelvis.

What information would be included when a disaster relief nurse counsels parents of young clients who have experienced a disaster? 1. Act as if things are normal. 2. Understand young children may exhibit separation fears and clinging. 3. Sedate the client until the crisis is resolved. 4. Understand nightmares and sleep disturbances may occur in young children. 5. Refrain from talking about the disaster.

2,4

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? 1. Memory loss 2. Difficulty focusing 3. Excessive sleepiness 4. Short-tempered 5. Hand-wringing

2,4,5

A client diagnosed with major depression has been admitted to a psychiatric facility for medication management. During nighttime rounds, an LPN/VN notes the client is not in bed. Which behavior by the client should the LPN/VN report to the RN immediately? 1. Sitting in a chair crying. 2. Reports inability to sleep. 3. Rearranging furniture. 4. Pacing around the room.

A client is admitted with new onset hyperthyroidism. Which medication is of concern to the nurse while reviewing the client's routine medications? 1. Ranitidine 2. Furosemide 3. Amiodarone 4. Propranolol

A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? 1. Bruising at the umbilicus. 2. Fever with tachycardia. 3. Positive Trousseau sign. 4. Pain radiating to back. 5. Vague pain at night.

1,2,4

A nurse is educating a group of community citizens about risk factors for developing peripheral neuropathy. Which risk factors should the nurse include? 1. Uncontrolled diabetes 2. Alcohol abuse 3. Vitamin A deficiency 4. Rheumatoid arthritis 5. Varicella-zoster virus

1,2,4,5

The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? 1. Grasps nurse's finger when placed in neonate's hand. 2. Toes curl downward when soles of feet stroked. 3. Turn's toward nurse's finger when cheek is touched. 4. Extends arms when nurse claps hands.

A client reporting right thigh pain is admitted to a local hospital with a diagnosis of deep vein thrombosis (DVT). During the admission assessment, the client develops new signs/symptoms. The nurse would be most concerned about what sign/symptom? 1. Swelling along vein of leg 2. Right foot begins to tingle 3. Restlessness 4. Warmth over affected area

After completing several rounds of chemotherapy, a client's laboratory results indicate severe neutropenia. Following admission assessment, what is the nurse's priority action for this client? 1. Notify dietary no fresh, unpeeled fruits or vegetables. 2. Avoid all venipunctures or IM injections. 3. Have client wear mask when leaving room. 4. Instruct client to use a soft toothbrush.

The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? 1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." 2. "Coughing and deep breathing are needed to prevent blood clots." 3. "Coughing and deep breathing will aide with healing by increasing available oxygen." 4. "Coughing and deep breathing will help resolve any blood clots that have formed. "

The unlicensed assistive personnel (UAP) reports to the nurse that a client who received morphine sulfate 4 mg IVP 30 minutes ago has a respiratory rate of 10 breaths/ minute. What is the nurse's priority intervention? 1. Administer naloxone 0.4 mg IVP. 2. Notify the primary healthcare provider of respiratory status. 3. Deliver breaths at 20 breaths/ minute via a bag-valve mask. 4. Instruct the UAP to ambulate the client.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

Which client would be appropriate for the charge nurse to assign to a room with a client who has undergone debulking of a tumor? 1. Client who is one day post laminectomy. 2. Client scheduled for a bone marrow transplant. 3. Client admitted with neutropenia. 4. Client being treated with intracavity radiation therapy.

An OB/GYN unit has recently discovered an increase in staphylococcus infections among both clients and staff, even though all cleaning procedures have been verified and upgraded. The infection control nurse is attempting to locate the source of the infection. The nurse knows which situations would likely not contribute to this problem? 1. A client in isolation receiving meals on disposable trays and dishes. 2. A client awaiting induction with a bouquet of flowers in the room. 3. A housekeeper sharing cleaning supplies with nighttime personnel. 4. A nurse sharing samples of a new hand cream with staff and clients. 5. A client recovering from a hysterectomy with large number of visitors.

1,2,3

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

1,2,4,5

What activities would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) caring for a client post-cholecystectomy? 1. Measuring and recording intake and output. 2. Assisting with ambulation in the hallway. 3. Reinforce information about a low fat diet. 4. Assisting with daily hygiene. 5. Measuring and recording vital signs. 6. Monitor for increased surgical site pain during activity.

1,2,4,5

What information about care of a plaster cast during the first 24 hours should the nurse provide to the client? 1. Keep the cast uncovered until it is completely dried. 2. Use the palms of your hands to position the cast for the first 24 hours. 3. Place an ice pack on top of the cast. 4. Elevate the extremity on a non-plastic pillow. 5. Do not do anything that would cause an indention on the cast.

1,2,4,5

The nurse is presenting discharge instructions, including dietary restrictions, to a client newly diagnosed with Cushing's disease. The nurse knows the teaching has been successful when the client chooses what selections? 1. Broiled cod, baked potato and steamed broccoli 2. Sliced ham with mashed potatoes and gravy 3. Beef taco with refried beans and guacamole 4. Lean cheeseburger with fries and fruit cocktail 5. Braised chicken with kale and navy bean salad

1,5

The nurse has been educating a client diagnosed with general anxiety disorder (GAD). Which statement by the client indicates the need for further education? 1. "I will avoid caffeine from now on." 2. "When I feel anxious I will increase my breathing to get more oxygen to my brain." 3. "I will go for a brisk walk when I begin to feel anxious." 4. "I will keep a diary of anxiety attacks to determine what triggers them."

The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement? 1. "There is nothing to help with this problem." 2. "You might hum when the voices are so troublesome." 3. "You should ask your primary healthcare provider to increase your medication." 4. "Wear earplugs to block out the voices."

A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important? 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.

2,3,4

The client shares that her husband died 2 months ago. She stays at home at least 3 times per week and cries most of the day. Which interventions for dealing with loss would the nurse initiate? 1. Resume previous social activities right away. 2. Establish a structure of daily activities. 3. Reinforce that dreaming about the loved one is positive. 4. Recommend immediate professional assistance. 5. Encourage communicating feelings during grief process.

2,3,5

Eight hours after a cholecystectomy a male client has tried unsuccessfully to urinate using a urinal in bed. Which nursing interventions would the nurse implement? 1. Insert a straight catheter. 2. Administer the prescribed PRN analgesic. 3. Assist the client to stand at the bedside to void. 4. Emphasize that the client must void within 2 hours. 5. Encourage the client to increase fluid intake to 500 mL/hr. 6. Assist the client to the bathroom and turn on running water.

2,3,6

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2,4

The nurse is planning care for the prevention of skin breakdown in a client diagnosed with a stroke. What intervention is important for the nurse to include? 1. Massage reddened skin areas located over bony prominences. 2. Place pillows under lower extremities to raise heels off the bed. 3. Position client on paralyzed side for one hour. 4. Apply emollients to dry skin. 5. Place a gel seat cushion on the wheelchair seat. 6. Shift client weight every two hours while sitting in a wheelchair.

2,4,5

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

A client with a history of rheumatoid arthritis has been taking large doses of NSAIDs to control daily discomfort. The healthcare provider recently prescribed misoprostol to decrease the client's risk of stomach ulcers secondary to the daily use of NSAIDs. At the following checkup, what information reported by the client should the nurse report immediately to the healthcare provider? 1. The client received a flu shot yesterday. 2. The client has developed nose bleeds. 3. The client's blood pressure is 145/85. 4. The client may possibly be pregnant.

A client with a history of schizophrenia is currently being treated in a mental health facility. The client wants to vote in an upcoming election. The nurse understands what is true about the legality of this action? 1. Primary healthcare provider can decide if client may vote. 2. Psychiatric clients cannot vote if taking medication. 3. A lawyer must approve the finished ballot. 4. An absentee ballot from the polling place can be obtained.

A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

The nurse is initiating the admission assessment on a client diagnosed with Parkinson Disease. The client is slow to answer questions and appears to be frustrated trying to find the right words. Which communication technique by the nurse is appropriate? 1. Share with the client that all will be OK. 2. Introduce another health issue to discuss with the client. 3. Identify other clients who have had communication issues. 4. Allow the client the opportunity to organize their response.

The nurse is making an initial home visit to a client newly diagnosed with diverticulitis. The client had been on a liquid diet but is now to begin solid foods appropriate for the disease process. The nurse knows dietary teaching has been successful when the client selects which meal? 1. Hamburger on sesame roll, macaroni and cheese, tossed salad 2. Lamb chop with brown rice, cooked broccoli, baked potato 3. Pork with sauerkraut, baked beans, and coconut cake 4. Spaghetti with meatballs, fruit cocktail, garlic bread

The primary healthcare provider has prescribed ampicillin and ciprofloxacin piggyback in the same hour, every 6 hours. How will the nurse administer these medications? 1. Administer one of the medications every 4 hours and the other every 6 hours. 2. Administer the medications by combining them into 150 mL of normal saline (NS). 3. Administer the medications at the same time by connecting the secondary tubing to two separate ports on the primary tubing. 4. Administer the medications separately, flushing with normal saline (NS) between medications.

Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider.

What room assignment would be best for the nurse to make for a primigravida with gestational diabetes who was admitted for glycemic control? 1. A private room near the nurses' station. 2. A room with a client admitted with a placenta previa. 3. A room with a client in preterm labor. 4. A room with a client admitted with pregestational diabetes.

In what order should the home health nurse see assigned clients? Place in priority order. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Client diagnosed with rheumatoid arthritis who requires an occupational consult.

This is the correct order

A nurse is caring for a poorly controlled type 2 diabetic client. The client does not adhere to the diet and the latest HbA1c is 8%. The serum glucose at this visit is 218mg/dL (12.09 mmol/L). The client is currently taking metformin and exenatide. Based on this history, what should the nurse anticipate will be the first strategy implemented to improve glucose control for this client? 1. Nutritional counseling 2. Increased daily exercise regimen 3. Education regarding Insulin by basal/bolus dosing method 4. More frequent self-monitoring of blood glucose

The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation? 1. 16 mm induration 2. 4 mm erythrokeratodemia 3. 0.1 mL bluish colored hard wheal 4. Multiple fluid-filled vesicles

The nurse is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would cause the nurse to re-assess the client prior to transfer? 1. "I just felt something gushing." 2. "I feel like I am still having contractions." 3. "When I stand up I feel dizzy for several moments" 4. "My nipples hurt since I breastfed my baby."

The nurse is reviewing medications for a client who is being treated for major depression. The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which over the counter medication/supplement taken by the client should be reported to the primary healthcare provider immediately? 1. Daily intake of St. John's Wort. 2. Daily intake of a multi-vitamin. 3. Occasional use of ibuprofen. 4. Twice daily intake of an antacid.

The nurse is reviewing the medication prescriptions with a client for which English is a second language (ESL). Which nursing intervention most likely will prevent a medication error with this client? 1. Use the teach-back method so that client is repeating the instructions back to the nurse. 2. Give printed information to the client. 3. Ask the client if they have questions before the client leaves the healthcare setting. 4. Refer medication questions to the pharmacist.

The nurse is teaching the parents of a child with impetigo about care. Which statement by the parents indicate further teaching is needed? 1. "We will not allow bathing until the scabs are healed." 2. "The skin and crusts will be washed daily with soap and water." 3. "Lotions should not be applied to the lesions, so they remain dry." 4. "We will apply the antibiotic ointment to the lesions after removing the crusts."

The nurse routinely screens injury victims for the possibility of intimate partner violence (IPV). Which statement correctly supports the nurse's action? 1. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. 2. IPV is not routinely seen in the upper socioeconomic level. 3. All women should be screened, but men are not routinely screened. 4. Only victims who enter the emergency department alone should be screened for IPV.

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further teaching is needed when the client makes which statement? 1. "The elbows should be flexed at 10 degrees." 2. "I should not lean on the crutches with my armpit." 3. "When going upstairs, my non-surgical leg goes up first." 4. "Both crutches are held in one hand when sitting down".

Which action by a nurse requires intervention by the charge nurse? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.

A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a Vanillylmandelic acid (VMA) urine test to be complete at home. What statement made by the client indicates the need for further teaching? 1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process." 4. "I need to throw away my first voiding when I start this test." 5. "I should void at the end of the 24 hours and keep that urine."

1,2,3

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1,2,3

A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include? 1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%. 4. Have estimated glomerular filtration rate measured every five years. 5. Increase protein intake to 30% of total calories eaten per day.

1,2,3

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.

1,2,3

A community health nurse, participating in a health fair, is educating a community group about risk factors for developing varicose veins. What risk factors should the nurse include? 1. Sitting for prolonged periods 2. Obesity 3. Female 4. Leg exercises 5. Wearing high-heeled shoes

1,2,3,5

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1,2,3,4

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. What should the nurse teach this client? 1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 4. "Eat foods such as tuna twice a week." 5. "Rise slowly from lying to sitting, or sitting to standing."

1,2,3,5

The nurse is caring for a client post heart transplant who is being discharged on cyclosporine and azathioprine. Which precautions would be important for the nurse to teach the client? 1. Avoid crowds. 2. Do not obtain live vaccinations. 3. Drink at least 3 liters of fluids per day and watch the urine for sediment. 4. Use a soft-bristled brush to clean your teeth. 5. Advise to use contraceptive measures during treatment.

1,2,4,5

A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What nursing interventions would be appropriate for the nurse to make? 1. Teach the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 3. Suggest that the client might recover faster by moving away from the coastal area. 4. Refer the client to the family primary healthcare provider for a complete physical examination. 5. Allow the client time to talk about the loss.

1,2,5

A nurse is planning to conduct primary prevention classes in a local community. Which initiatives should the nurse include? 1. Parenting classes for first time parents 2. Healthy diet classes for school-age children 3. Breast self-examination classes 4. Cardiac rehabilitation classes 5. Community exercise classes to promote weight loss

1,2,5

A client with type 2 diabetes, who is noncompliant, has a HbA1c of 8%. The finger stick blood sugar is 218 mg/dL (12.1 mmol/L) at 0900. The current medications prescribed are metformin and exenatide. Based on this data, what teaching should the nurse reinforce? 1. Nutritional counseling to help improve diet compliance 2. HbA1c measures glycemia control over a period of 1 month 3. Blood glucose testing 4. HbA1c of 8% tells us that your average glucose level is 180 mg/dL (10 mmol/L) 5. Without glycemic control, eye complications can occur

1,3,4,5

A pediatric nurse is teaching a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include? 1. At 4 weeks of age, the infant should be able to gaze at objects. 2. Infants should have tears by the age of 1 month. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.

1,3,4,5

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1,3,5

The nursing supervisor is notified by staff in the sterilization room that a foul odor has been noted. Upon inspecting the room, the nurse notes a small amount of sewage seeping up thru the floor drain. What priority actions should the supervisor initiate? 1. Evacuate staff from the room and lock the door. 2. Tell staff to remove any equipment already sterilized. 3. Report the incident to the administrative Chief Executive Officer (CEO). 4. Call maintenance to thoroughly clean the room. 5. Initiate 'internal disaster protocols' immediately.

1,3,5

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the air flow on the continuous positive airway pressure (CPAP) machine.

1,3,5

Which of the following should the nurse teach regarding nutrition for a client with celiac disease? 1. Gluten is a protein found in wheat and oats. 2. A gluten intolerant person can eat foods that are made with barley or rye. 3. Fruits can be eaten on a gluten free diet. 4. Gluten causes inflammation of the large intestines of people with celiac disease. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

1,3,5

The nurse is teaching a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? 1. Promote a diet rich in fruits and vegetables. 2. Provide instruction on benefits of carotid endarterectomy. 3. Limit sodium intake to 2 grams/day. 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

1,3,5,6

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should be assigned to the medical surgical nurse? 1. Total abdominal hysterectomy (TAH). 2. Client post C-section to be discharged home. 3. Breast Reduction. 4. Vaginal delivery of fetal demise. 5. 28 week gestation of bed rest. 6. Bladder suspension with anterior and posterior repair.

1,3,6

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. To self-determination 2. To decline participation in research studies and experimental treatments 3. To expect reasonable continuity of care 4. To make decisions about the plan of care 5. To advocacy

1,4

The charge nurse is observing a new nurse administer cortisporin otic to the left ear of a 2 year old child. What action by the new nurse would indicate that the charge nurse needs to intervene? 1. Position the client prone, with affected ear up. 2. Pull pinna down and back. 3. Administers medication at room temperature. 4. Allow child to sit up once medication is instilled. 5. Educate parents that the medication may burn when instilled.

1,4

The nurse is caring for a client on the surgical unit. Which prescriptions could the nurse safely administer to the client? 1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 2. Regular insulin 10 U stat 3. MS 2 mg IVP every 2 hours as needed for pain 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights

1,4,5

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1,4,5

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an intrauterine device (IUD) is most appropriate for what individuals? 1. A mother of a toddler who wants another child in three years. 2. The client with a recent exacerbation of sickle cell anemia. 3. A client with stage II breast cancer who has finished chemotherapy. 4. An adolescent who has recently become sexually active. 5. The client with a double mastectomy seven years ago.

1,5

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. "Vaccinations give antibodies to your baby to protect them from disease." 2. "Vaccinations will help your baby produce antibodies against disease causing organisms." 3. "Federal law requires that your baby receive recommended vaccinations." 4. "There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur."

A new nurse is anxious about being assigned to a a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? 1. "What you really mean is that you fear a client with violent episodes." 2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." 3. "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." 4. "You attended an in-service during orientation on dealing with the client with violent behavior."

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, crushing the tablet and mixing it into 3 ounces of applesauce, the new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

A teenager leaves class in the middle of an exam to go to the school nurse's office. The student reports difficulty sleeping for several days, increasing nervousness, irritability, and palpitations. The nurse notes flushing of the skin, and an irregular heartbeat. What would be the best question for the nurse to ask this client? 1. "Do you feel this way because you are afraid that you are failing the exam?" 2. "Have you been drinking energy drinks while studying for your exam?" 3. "What drugs are you taking?" 4. "Do you want me to call your mother?"

A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? 1. "I understand you are upset, but you will have to go back to your unit sooner or later." 2. "You are repressing this event because it was frightening and painful for you." 3. "In my professional opinion, you are trying to undo what happened in the battle." 4. "You are splitting from the bad you, so that the good you survives."

After completing the initial morning assessment of a client, the nurse notes that a dose of intranasal desmopressin is to be administered. What action is most important for the nurse to take? Exhibit 1. Measure urine osmolality. 2. Hold desmopressin dose. 3. Administer acetaminophen for headache. 4. Instruct client on intranasal administration of desmopressin.

Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure? 1. Decreased pain in the extremity 2. Prompt capillary refill < 2 seconds after blanching 3. Bleeding at the site of the incision 4. Ability of the client to wiggle his/her fingers

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

The family of a client receiving treatment for substance abuse asks why they should get involved in treatment plan. Which statement by the nurse would best explain the rationale for including the family in the treatment plan? 1. "The treatment plan consists of having the family confront the client about the harm substance abuse causes." 2. "Family involvement reduces distress in family relationships to lessen the risk for relapse by the client" 3. "Involving the family helps the family learn ways to protect the client from additional harm." 4. "The family assists in ways to help reduce temptations for substances by the client."

The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After assessing the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.

The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate electrolyte intake through foods and/or dietary supplements. Which foods should the nurse suggest to the client? 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries

Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? 1. Vital lung capacity of 900 mL. 2. Breathlessness while talking. 3. Heart rate of 98 beats per minute. 4. Respiratory rate of 24 breaths per minute.

Which assigned client should the nurse see first? 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours.

Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.

Which menu selection by the client diagnosed with cholelithiasis indicates to the nurse that teaching of proper diet was understood? 1. Fried chicken, rice and gravy, broccoli and cheese, custard pie 2. Grilled pork chops in peach sauce, baked sweet potato, sherbet 3. Oven roasted bbq ribs, baked beans, tomato slices, ice cream 4. Pasta topped with boiled shrimp and butter sauce, salad, bread pudding

The nurse is planning care for a client admitted with a diagnosis of new onset myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? 1. Provide thin liquids such as water with meals. 2. Offer small bites of food. 3. Allow client to rest between each bite of food. 4. Offer small meals in the morning and larger meals in the evening. 5. Position client upright with head tilted slightly back when eating. 6. Provide meals 30 minutes before administration of cholinesterase inhibitor medication.

2,3

The nurse is teaching a group of teenagers about decreasing the risk of developing skin cancer. What information should the nurse include? 1. Use sunscreen with a sun protection factor (SPF) of at least 30. 2. A self-tanning product containing dihydroxyacetone (DHA) is safe to use. 3. Put on sunscreen every day, even on days when it is cloudy. 4. Stay in the shade between 9 AM and 4 PM. 5. Tanning beds are safer than outdoor tanning.

2,3,4

Two hours after admission, a client reports palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thread pulse, and a BP of 90/50. Which action should the nurse take? Select all that apply. Exhibit 1. Administer Lidocaine 50 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. 5. Perform carotid massage. 6. Begin cardiopulmonary resuscitation.

2,3,4

The home care nurse, working with an infant in the home, is concerned about the infant developing diaper rash from wearing cloth diapers. Which strategies should the nurse teach to the parents to prevent skin irritation? 1. Change diapers every four hours. 2. Wash diapers with hypoallergenic detergent. 3. Rinse diapers twice when washing. 4. Apply a protective ointment to diaper area with each diaper change. 5. Check infant at least hourly for wet or soiled diapers.

2,3,4,5

The nurse is updating the client's plan of care 24 hours after admission. What data would indicate to the nurse that the client is improving? Exhibit 1. Troponin T - 0.10 ng/mL 2. Coughing up moderate amount of clear to white sputum 3. Urinary output past 8 hours - 225 mL 4. BP - 100/64, Respirations - 18/min, Temperature - 99.2° F (37.3° C) 5. Current Telemetry ECG

2,4,5

What should the nurse include when planning discharge teaching for a client post scleral buckling of the right eye? 1. Redness, tenderness and swelling should be gone within 2 days. 2. Teach to report seeing flashes of light immediately. 3. Place eye drops onto the cornea of the affected eye. 4. Wear eye shield during naps, and at night. 5. Have client demonstrate the correct technique for instilling eye drops.

2,4,5

After a thoracotomy, which interventions will the nurse initiate to reduce the risk of acute respiratory distress? 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

2,5

The client's primary healthcare provider orders a blood transfusion for a client whose hemoglobin level is 5.0 mg/dL (3.103 mmol/L). The nurse informs the client that blood will be drawn for a type and cross-match prior to the blood transfusion. The client avoids eye contact with the nurse and states, "I am a Jehovah's Witness. I thought that was on my chart." The nurse demonstrates the role of client advocate by which response to the client? 1. "Your hemoglobin is very low. I can notify your primary healthcare provider to discuss with you how important it is for you to receive the blood." 2. "I will place that information in your medical record. You have the right to refuse treatment which conflicts with your beliefs." 3. "Your primary healthcare provider ordered this blood transfusion because your hemoglobin is low." 4. "Why do Jehovah's Witnesses choose not to receive blood transfusions?" 5. "Would you like to speak with your primary healthcare provider about other treatment options?"

2,5

A client diagnosed with a right embolic stroke is admitted to the rehabilitation unit. The client is presenting with dysphagia. Which nursing intervention would the nurse implement for a client with dysphagia? 1. Flex the neck backwards 2. Request a liquid diet for the client 3. Place food on the right side of the mouth 4. Turn the client's plate around halfway through the meal

A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? 1. I know that I must take this medication until my primary healthcare provider tells me to stop. 2. It is frustrating to have to follow dietary restrictions. 3. I am getting a cold, and I am going to take some over the counter cold medicine. 4. I am going to have broccoli salad and roasted turkey for lunch today.

The behavioral health nurse is providing crisis intervention follow-up with a client and is teaching concepts regarding crises. Which statement by the client would best indicate understanding of the teaching? 1. "I must have a type of mental illness because I was not able to cope with the stressful situation." 2. "I will usually not be able to identify a stressor that can cause a crisis in my life." 3. "This crisis has the potential to help me grow psychologically." 4. "Because this situation created a crisis for me, I can expect this crisis to recur for me."

The extended family of an alert 92 year old widower has decided the client needs a PEG tube because of weight loss and extremely poor appetite. Though the client is not agreeable, the family is quite insistent and pressures the client to give consent. What action by the nurse would best encourage the client to speak up about personal wishes? 1. Leave personal cell number for client to call after family leaves. 2. Notify family that client has the right to refuse PEG tube insertion. 3. Ask client directly about personal fear or concerns regarding tube. 4. Inform healthcare provider the client does not want feeding tube.

The nurse is caring for a client in an outpatient clinic. The client's spouse died 8 months ago. Which statement by the client suggests that the client is achieving resolution of grief? 1. "I am starting a new life, so I have removed all of the pictures from the wall that remind me of my spouse." 2. "I'm so lonely and I'm not sure life is worth living now." 3. "Although it hasn't been easy, I accept the loss of my soul mate." 4. "If only we had spent more time together before the illness got so severe."

The nurse is passing morning medication on a busy medical-surgical unit and has been delayed in completing rounds. When re-evaluating how to distribute the remaining scheduled medications, which client would the nurse consider at greatest risk if medications are late? 1. The client with congestive heart failure receiving digoxin. 2. The client with epilepsy scheduled to receive phenytoin. 3. The client with myasthenia gravis on pyridostigmine. 4. The client with hypertension due for daily nifedipine.

Which statement made by the nurse is therapeutic when the client, who has experienced deficits from a recent cerebral vascular accident, tearfully states, "I can no longer care for myself."? 1. "Right now, I am going to help you get dressed and eat breakfast." 2. "You have to focus on the positive things in your life." 3. "It is hard not to be able to care for yourself." 4. "All you need is some physical therapy and you will be back to normal soon."

The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as most indicative for a fecal impaction? 1. Rigid, board-like abdomen 2. Absence of any bowel sounds 3. Diarrhea with severe cramping 4. Constipation with liquid seepage

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1,2,3,5,6

A 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature: 100.8ºF/38.2ºC, pulse: 94, respiration: 28 and blood pressure is 146/90. What is the nurse's best action? 1. Call the surgeon immediately. 2. Administer extra strength acetaminophen per prescription. 3. Assess the surgical site. 4. Offer extra blankets and increase fluids.

The nurse is preparing to make initial shift rounds. Which primipara client should the nurse see first? 1. 39 weeks with a board like abdomen and scant dark red bleeding. 2. 38 weeks gestation with blood streaked vaginal discharge 3. 40 weeks gestation reporting urinary frequency 4. 36 weeks gestation with pitting pedal edema

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1,2

What signs/symptoms would the nurse expect to find in a client diagnosed with acute pyelonephritis? 1. Chills 2. Fishy smelling urine 3. Polyuria 4. Dysuria 5. Headache

1,2,4

A child is brought into the emergency department (ED) after accidently ingesting 3 grams of acetylsalicylic acid. Initial assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia. What interventions should the nurse initiate? 1. Provide tepid water sponge bath. 2. Start an IV for fluid resuscitation. 3. Insert a nasogastric tube. 4. Pad side rails. 5. Obtain blood gases. 6. Administer ipecac syrup orally.

1,2,3,4,5

A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious". What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? 1. Agitation 2. Insomnia 3. Course tremors 4. Visual hallucinations 5. Confabulation 6. Tachycardia

1,2,3,6

Which assessment finding on a client four hours post right femoral percutaneous transluminal coronary angioplasty (PTCA) would require immediate intervention by the nurse? 1. Client reports chest discomfort. 2. Legs elevated 15 degrees. 3. Pressure dressing over puncture site intact/dry. 4. Client reports slight tingling to right foot. 5. Left pedal pulse 2+/4+, Right pedal pulse 1+/4+.

1,2,4,5

The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion is noted on the client's forehead. Which information should the nurse include in the incident report? 1. Abrasion on the client's forehead. 2. Client's perspective as to why they fell. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up.

1,3,4,5

The nurse is talking with a new parent regarding activities that promote attachment between the parents and the newborn. What activities should the nurse include? 1. Feed baby on demand. 2. Put baby in bed to sleep with parents. 3. Allow baby to cry for at least 5 minutes. 4. Sing to the baby. 5. Stroke baby's face.

1,4,5

A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What is the client most likely experiencing? 1. Hyperventilation 2. Panic disorder 3. Somatization 4. Conversion disorder

The nurse is admitting an elderly client reporting abdominal pain. During assessment, the client answers inappropriately or just smiles in response to questions. What should the nurse suspect is the most likely cause for this behavior? 1. Developmental delay 2. Hearing difficulty 3. Pain 4. Confusion

A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Ask the client to sit for a few minutes. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Inform the client that their actions are unacceptable.

A postpartum client is receiving methylergonovine maleate 0.2 mg by mouth three times a day. What is most important for the nurse to monitor with this client? 1. Dizziness 2. Hypertension 3. Nausea and vomiting 4. Headache

The nurse is planning discharge teaching for a client with thrombocytopenia. Which should the nurse include? 1. Floss between teeth daily. 2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitted shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma.

2,3,4,5

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2,3,4,6

The nurse is caring for a heart failure client taking spironolactone. Which snack choices would indicate to the nurse that the client understands proper dietary choices while on this medication? 1. Bananas 2. Cheese and crackers 3. Apples 4. Sweet potatoes 5. Grapes

3,5

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled baby to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.

Which action by the nurse administering intravenous ciprofloxacin would require intervention by the charge nurse? 1. Sets IV pump to administer ciprofloxacin over a period of 30 minutes. 2. Educates client that medication may cause dizziness. 3. Instructs client to notify nurse for any tendon pain. 4. Administers ciprofloxacin through 20 gauge catheter into the cephalic vein.

Which signs/symptoms should the nurse assess for in the client admitted with a diagnosis of myasthenia gravis? 1. Difficulty holding head erect 2. Limited facial expressions 3. Ptosis 4. Hemiparesis 5. Writhing, twisting movements of the body 6. Pill rolling

1,2,3

The nurse is preparing to educate a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include? 1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. 5. Reduce sodium intake to less than 2700 mg/day.

1,2,3,4

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of initial treatment therapy. What side effects should the nurse teach the client are expected? 1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure

1,2,4,5

A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? Exhibit 1. Have client cough and deep breathe. 2. Administer acetaminophen for fever 3. Administer the prescribed analgesic 4. Assist the client to ambulate.

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? 1. The drainage is continuous but slow. 2. The drainage is cloudy and dark yellow. 3. The drainage is bright red. 4. No drainage of urine or irrigation solution is noted.

Which prescription should the nurse question for a client diagnosed with heart failure who has a Swan-Ganz mean pulmonary artery pressure of 20 mm Hg? 1. Oxygen 2 liters/nasal cannula 2. Furosemide 40 mg IV push stat 3. Normal saline infusion at 100 mL/hr 4. Pulse oximetry monitoring

The charge nurse is making assignments for the evening shift. Which client would be an appropriate assignment for a new LPN/VN graduate? 1. A middle aged adult admitted with syncope. 2. An adolescent with skin grafts to right hand. 3. A young adult receiving IV chemotherapy. 4. An elderly adult diagnosed with diverticulitis.

The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.

The nurse is monitoring care provided to clients by a newly hired unlicensed assistive personnel (UAP). Which action by the UAP would require the nurse to intervene? 1. Uses a gait belt when ambulating a client with right sided weakness. 2. Repositions a client in bed using a lift sheet. 3. Disconnects nasogastric (NG) tube from suction to allow ambulation to toilet. 4. Massages a surgical client's calf after reports of leg cramping.

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain

1,2,4,5

The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)? 1. Assist with bottle feeding newborns in the nursery. 2. Completing perineal care for post-delivery clients. 3. Observing a Cesarean section for co-joined twins. 4. Ambulate client to bathroom following delivery.

The client arrives in the emergency department with crushing substernal chest pain radiating down the left arm. Which measure should the nurse initiate first? 1. Attach to a cardiac monitor 2. Administer oxygen at 2 L/nasal cannula 3. Start an intravenous (IV) line of D5W to keep open 4. Draw blood for troponin level

The nurse should wear gloves when administering which medication? 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.

2,3,5

A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.

2,5

A newly hired nurse from South America is being oriented to a medical-surgical unit. The hospital recently changed to a digital computer system, including laptop stations in client rooms for documentation. The new nurse resists using the system, indicating the process is "too advanced to learn". What is the most appropriate action by the charge nurse? 1. Report the nurse's refusal to the supervisor for disciplinary action. 2. Have the new nurse shadow staff to observe the computer process. 3. Arrange for nurse to receive special training by education department. 4. Assign only personal care to the nurse until able to use the new system.

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg

The nurse is caring for four clients. Which client should the nurse see first? 1. The client hospitalized with dehydration related to diarrhea. 2. The seizure client who is currently in the postictal phase. 3. The post-op client who received Morphine 4 mg IV 15 minutes ago. 4. The client who is due pre-op medication now.

What action should the nurse take when testing a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.

The nurse is caring for a client diagnosed with Obsessive Compulsive Disorder (OCD). Which statement, made by the client, would be the best indicator of improvement? 1. "My friends don't know I have OCD." 2. "I only do my hand washing to reward myself when I am good." 3. "I know my thoughts and behaviors aren't very normal." 4. "I have more control over my thoughts and behaviors."

The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation? 1. 15 mm induration 2. 4 mm erythrokeratodemia 3. 0.1 mL bluish colored hard wheal 4. 0 mm induration

What should the nurse consider when caring for a client who is receiving total parenteral nutrition (TPN)? 1. Will need a central line. 2. TPN requires a dedicated line. 3. Weigh the client daily. 4. Check the urine for protein. 5. TPN can only be hung for 12 hours

1,2,3

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? 1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis

1,2,3,5,6

The psychiatric nurse notices a new client sitting alone in the dayroom, shaking and muttering indistinguishable words. What statement by the nurse is appropriate? 1. "Who are you talking to?" 2. "You look like you are cold." 3. "It is always cold in this room." 4. "Do you want to get a sweater?"

A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? 1. Afebrile 2. Cullen's Sign 3. Pain relieved after eating 4. Positive Chvostek's sign 5. Tachycardia.

2,5

A nurse caring for a client diagnosed with osteomyelitis instructs an experienced unlicensed assistive personnel (UAP) to obtain vital signs on the client. Which value should the nurse tell the UAP to report immediately? 1. Heart rate 98/min 2. Respirations 22/min 3. Blood pressure 138/82 4. Temperature 101°F (38.3°C)

A nurse has completed pre-operative instructions for an elderly client scheduled for a cholecystectomy. The following client's statement reflects a need for additional pre-operative instructions. 1. "I may have several small incisions." 2. "I may need to stay in the hospital overnight." 3. "I will ask my husband to bring my medications." 4. "My daughter had lots of problems after this surgery"

A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.

Two days after being prescribed enoxaparin the nurse notes hematemesis. Lab work has been obtained. Based on this data what action is most important for the nurse to take? Exhibit 1. Administer protamine sulfate. 2. Administer the next dose of enoxaparin. 3. Obtain vital signs. 4. Insert a nasogastric tube.

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? You answered this question Incorrectly 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1,2,3,4,5

The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose? 1. Hypoventilation 2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration 6. Hypothermia

2,3,4,5

The nurse is caring for a client with body dysmorphic disorder. The client tells the nurse, "My ugly ears make everyone sick!" Which defense mechanism is this client utilizing? 1. Sublimation 2. Somatization 3. Symbolism 4. Projection 5. Conversion

3,4

The nurse is reviewing the Patient Care Analgesia (PCA) pump settings delivering hydromorphone to a client. Based on the available information, what is the maximum mg amount of hydromorphone the client can receive via PCA dosing? Answer using numbers and decimals only. Exhibit

0.3

The nurse is preparing to administer 500 mL Normal Saline to a client over the next two hours per infusion pump. What number should the nurse set the pump at to deliver the prescribed amount per hour?

250

The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 20 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.

The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. In what order should the nurse present this information? List the order in which blood flows through the heart, starting from deoxygenated blood in the body. Vena Cava Right Atrium Right Ventricle Lungs Left Atrium Left Ventricle Aorta

This is the correct order

The primary healthcare provider has prescribed ear irrigation for a client with earwax accumulation. In what order would the nurse perform the procedure? Fill bulb syringe with luke warm water. Tilt client's head to the opposite side. Pull ear pinna upward and backward. Aim syringe at back side of ear canal. Squeeze syringe with moderate force. Remove any debris in the outer canal.

This is the correct order

A newly married wife tells the nurse, "I told my husband that I may not know how to cook, but I can sure do the dishes!" Which defense mechanism is the client displaying? 1. Projection 2. Displacement 3. Sublimation 4. Compensation

Shortly after being admitted to the cardiac unit, a client reports shortness of breath. The nurse prepares to administer the prescribed morphine. How many mL should the nurse administer? Use numbers and decimals only to answer. Exhibit

0.4

A nurse is providing dietary instructions for a client diagnosed with liver disease. Which food should the nurse instruct the client to increase in their diet? 1. Pasta 2. Olive oil 3. Spinach 4. Cantaloupe

In what position should the nurse place a client post intracranial surgery? 1. Head of bed elevated 30 degrees 2. Supine 3. Dorsal recumbent 4. Recovery position

A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse? 1. Anxiety 2. BP 136/80 3. CVP 5 mmHg 4. Crackles noted right posterior lung field 5. S3 heart sound

1,4,5

A client with a history of adrenal insufficiency is placed on fludrocortisone. Which value is most important for the nurse to monitor? 1. Magnesium 2. Weight 3. Pain 4. Glucose

After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? Exhibit 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? 1. Abstract reasoning 2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior

2,3,4,5

In what position should the nurse place a client diagnosed with gastric reflux? 1. Orthopneic 2. Semi-Fowler's 3. Sims' 4. Reverse Trendelenburg

Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged.

This is the correct order

The nurse initiates sterile wound care on a client's newly debrided foot ulcer. After removing the dressing and beginning a betadine cleanse, the client mentions an allergy to iodine not previously reported. Place the nursing actions in order of priority. Ask client about the type of "allergic response". Remove betadine solution from wound with normal saline. Cover wound with temporary sterile dressing. Observe client for signs or symptoms of reaction. Notify primary healthcare provider of the allergy.

This is the correct order

The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? Wash hands and apply gloves. Clamp IV line closed securely. Stabilize cannula with one hand. Loosen tape and tegaderm cover. Apply gauze and tape tightly.

This is the correct order

After applying sterile gloves, what process should the nurse use to remove interrupted sutures from a client's surgical wound? Place in the correct order. Moisten dried crust with sterile 0.9% sodium chloride solution. Clean suture line with antimicrobial solution. Gently grasp the knot with forceps and raise it slightly. Place the curved tip of suture scissors directly under the knot. Gently cut the suture. Pull suture out with forceps. Make certain all suture material is removed. Put suture on clean gauze. Apply sterile wound strips. Document date, time, and number of sutures removed.

This is the correct order

Four clients arrive for their appointment at a diabetic clinic. In what order should the nurse see the clients? Client reporting a headache and has a fruity breath. Client eating a simple-carb snack due to weakness. Client scheduled for a dressing change to foot ulcer. Client to receive dietary education.

This is the correct order

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. Client's tracheostomy needs to be suctioned. The water seal chamber is empty in a client's closed chest drainage unit. UAP reports a heart rate of 40/min in a client. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.

This is the correct order

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury? 1. Increased pulse 2. Rhinorrhea 3. BP 150/60 4. Papilledema 5. Projectile vomiting

2,3,4,5

An adolescent has been admitted for evaluation of excessive weight loss over several months. When assessing the client, what data gathered by the nurse would be most important to support a diagnosis of anorexia nervosa? 1. Dehydration 2. Poor appetite 3. Amenorrhea 4. Tachycardia 5. Muscle loss 6. Constipation

1,3,5,6

A client rescued from a house fireis being treated for burns to both arms and suspected inhalation injury. What data collected by the nurse has the highest priority? 1. Estimation of total surface burn area 2. Characteristics of cough and sputum 3. Calculation of client weight and age 4. Extent of edema to arms

A 68 year old client was admitted two days ago to a long term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/min by nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? Exhibit 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

The charge nurse at a long-term care facility is discussing restraint policies with new staff members. The nurse explains that the use of restraints are only appropriate for what reasons? 1. Reduce wandering throughout the night shift. 2. Prevent confused client from exiting the building. 3. Keep combative clients from injuring staff or clients. 4. Eliminate any falls when the client is sitting in a chair. 5. Decrease potential for pulling out I.V.'s or dressings.

3,5

5,6

Which teaching points should the nurse include when preparing the school-age child for heart surgery? 1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 3. Explain that an endotracheal tube will be needed. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

1,2,4,5

What should a nurse include when preparing to educate a female client on how to prevent recurrent cystitis? 1. Drink at least eight, 4 ounce glasses of water per day. 2. Urinate as soon as the urge occurs. 3. Avoid irritating perineum with harsh soap. 4. Empty your bladder post coitus. 5. Avoid use of a diaphragm.

2,3,4,5

A client receiving treatment for hypertension is scheduled to receive hydrochlorothiazide 25 mg orally. Based on the label on the bottle, how many tablets should the nurse administer? Exhibit

0.5

Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Which client can be assigned to the LPN? 1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

1,2,5

What term should the nurse use to document that a woman is pregnant for the first time? 1. Primigravida 2. Multigravida 3. Primipara 4. Multipara

The nurse recognizes which manifestations as signs of community-acquired pneumonia? 1. Cough 2. Decreased respiratory rate 3. Fever 4. Myalgia 5. Pleuritic chest pain

1,3,4,5

A nurse suspects that a client admitted to the emergency department is in a hyperosmolar hyperglycemic diabetic state. What data would lead the nurse to this conclusion? 1. Excessive thirst 2. Fruity-smelling breath 3. Kussmaul respirations 4. Metabolic acidosis 5. Polyuria

1,5

The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.

4,5

The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease

The nurse is preparing to administer cefazolin 0.5 grams in 100 mL D5W IVPB over 30 minutes. How many mL/hour will the nurse need to set the IV infusiton pump at? Round to the nearest whole number.

200

The nurse is checking a nine month old's developmental status. What finding would be of concern to the nurse? 1. Unable to transfer a toy from one hand to the other hand. 2. Cannot stand without support. 3. Does not notice or mind when a parent leaves. 4. Has not acquired a 6 word vocabulary.

The primary healthcare provider has prescribed KCL 20 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

12.5

A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

A client diagnosed with renal failure has been admitted to the medical unit. An arterial blood gas (ABG) analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? Exhibit 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.

A client was prescribed a monoamine oxidase inhibitor (MAOI) for the treatment of depression. Which comment by the client indicates adequate understanding of the tyramine restrictions that apply? 1. I cannot eat avocados or smoked ham. 2. I can eat sausage for breakfast, but not bacon. 3. At least I can still have my beer. 4. I can have blue cheese on my salad but not ranch dressing.

A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? 1. Go to the client to assess for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.

A female client with a history of frequent exacerbations of asthma asks the nurse to explain to her why she is at greater risk for fractures than other women her age. What is the nurse's best response? 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm

1,3,5

The nurse is caring for a client diagnosed with chronic renal failure who has been taking Epoetin alfa for 2 months. What should the nurse monitor for pertaining to Epoetin alfa during the client's clinic visit? 1. Hypertension 2. Halitosis 3. Hemoptysis 4. Oliguia 5. Dependent edema

1,3,5

The nurse is observing a new RN explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new RN understands the phototherapy process when what statements are made to the mother? 1. "The infant's eyes must be covered throughout the light session." 2. "The heat from the light may cause some harmless swelling in arms." 3. "Body temperature must be checked frequently to monitor for fever." 4. "It is important to restrict feedings during the phototherapy sessions." 5. "We check bilirubin levels several times daily to be sure it's decreasing."

1,3,5

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1,2,3,4

The homecare nurse is instructing a client with chronic obstructive pulmonary disease (COPD) about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1,2,3,4

A newly appointed nurse manager on the unit has a stable staff who have worked together for 5 or more years. The unlicensed assistive personnel (UAPs) are accustomed to informally arranging their lunch time; however, the nurse manager has implemented a plan to assign breaks and lunch. The UAPs are angry and refuse to change to the new system. What should be the nurse manager's first action in this situation? 1. Plan a unit staff meeting to discuss the problem and receive input for resolution. 2. Inform the staff that the plan will be implemented and those not following the plan will be disciplined. 3. Ask the charge nurse to address the problem daily as it occurs. 4. Plan a meeting with all UAPs to discuss the problem and reason for the new assignments.

A nurse is caring for a client that is undergoing outpatient psychiatric treatment for somatization disorder. Which statement by the client indicates that teaching has been successful? 1. "I will keep a diary of times of stress and the appearance of physical symptoms." 2. "I will simply ignore any physical symptoms I get from now on." 3. "The best way for me to stop having physical symptoms is to avoid all the stress in my life." 4. "I will take a sedative when I start having physical symptoms."

A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will prevent further chemical exposure? 1. Don appropriate personal protective equipment (PPE). 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

A nurse is planning to conduct parenting classes for first time parents in an attempt to decrease child abuse in the community. What type of prevention is the nurse utilizing? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Case management

A nurse is working in a walk-in clinic where a mother brings in her 6 year old child stating, "My child is just not right." The nurse notes an unusual odor to the child's breath, new onset of bed-wetting, and lethargy. What prescription by the primary healthcare provider should be performed first? 1. Blood glucose 2. Urinalysis for white blood cells (WBC) 3. Oxygen saturation 4. Toxicology screen

A nurse observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client most likely experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

A nurse on the unit has had a disagreement with the family of a client regarding the client's dressing change. What is the best action by the nurse manager? 1. Meet with the family member and the RN to discuss the disagreement. 2. Assure the family member that the nurse followed the hospital procedure. 3. Discuss the dressing change procedure with the RN and compare to a current textbook. 4. Report the argument to the hospital administrator.

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry.

1,2,3,4

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure

1,2,3,4

The nurse is developing a teaching plan for a female client who is taking one of the thiazolidinediones for the treatment of type 2 diabetes. What instruction should be included in the teaching plan? 1. Make sure that you use effective contraception while taking this drug. 2. The drug may lead to weight loss. 3. Therapeutic effect is reached within one to two weeks. 4. Therapeutic effect is reached within one month.

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

The nurse manager of a long-term care facility notes an increase in pressure ulcers over the last six months. What new protocol developed by the nurse manager is most likely to decrease the occurrence of decubiti? 1. Bedfast clients must be repositioned every two hours. 2. All clients should have egg crate mattress on the bed. 3. Clients bathed in bed need lotion applied to all joints. 4. Provide back massage daily to all clients on bed rest.

The nurse tries to notify the primary healthcare provider (PHP) that the dosage of newly prescribed medication is higher than recommended. The PHP cannot be located and the medication is scheduled to be administered in 30 minutes. Which intervention should the nurse implement next? 1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.

The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? Exhibit 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.

When assessing the client with acute myeloid leukemia the nurse notes the client has pain from mucositis, fatigue from slight activity, pulse rate 100, respiratory rate 22, blood pressure 130/64 mmHg, temperature 98.9 F, and petechiae on the arms. What action should the nurse take first? 1. Administer pain medicine. 2. Notify primary healthcare provider of petechiae. 3. Encourage fluid intake and foods high in protein. 4. Have the UAP assist the client when ambulating.

Which activity should the nurse recognize as increasing the risk for a client developing a community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection? 1. Taking wrestling classes at the gym once a week. 2. Traveling on an airplane next to someone coughing. 3. Eating raw fruits without washing them. 4. Working in close proximity to several co-workers.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

Which client is at the greatest risk for developing pancreatic cancer? 1. 70 year old obese client who smokes one pack of cigarettes a day 2. 64 year old client who had gallbladder surgery less than 5 years ago 3. 58 year old client with Chron's Disease 4. 52 year old client whose mother died from pancreatic cancer

Which client should the RN assess first? 1. Client experiencing unstable angina. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client five days post right-sided cerebral vascular accident. 4. Client diagnosed with Bell's palsy scheduled to be discharged.

Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."

Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.

A nurse is teaching a client the advantages of having a PICC line inserted rather than a peripheral IV. What information should the nurse include? 1. TPN may be infused using a PICC line. 2. Use of a PICC can allow for early client discharge. 3. PICC lines do not have to be replaced as often as a peripheral IV line. 4. PICC lines have the same risk of infection as a peripheral IV line. 5. PICC lines do not need to be flushed as frequently. 6. PICC placement decreases the need for skin puncture when blood sampling is needed.

1,2,3,6

A client has been admitted to Hospice Care. The hospice nurse is reviewing the nursing care plan for interventions to promote comfort for the terminally ill client. Which nursing interventions for the terminally ill client would the nurse implement? 1. Provide oral care every 2 hours. 2. Provide supportive environment. 3. Encourage 3 meals a day. 4. Administer optical lubricants as needed. 5. Encourage client to ambulate every 4 hours.

1,2,4

A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

1,2,4,5

After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? 1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 3. Have dietary puree foods. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.

1,2,4,5

The nurse is caring for a client in the emergency department with a suspected arm fracture. What assessment data would support this finding? 1. Pain and tenderness at the fracture site 2. Unnatural movement 3. Stiffness in the arm 4. Shortening of the extremity 5. Deformity of the extremity

1,2,4,5

The nurse is teaching a group of clients how to decrease the risk of developing osteoarthritis (OA). What should the nurse include? 1. Control blood sugar. 2. Use largest, strongest joints for lifting. 3. Do intense aerobic exercise, daily. 4. Maintain a healthy weight. 5. Wear joint padding with playing sports.

1,2,4,5

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis? 1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 3. Decrease fluid intake to 1 liter/day. 4. Advise client wear protective clothes outside while taking levofloxacin. 5. Monitor for hypotension, tachycardia, fever.

1,2,4,5

Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Hemoglobin of 11 mg/dL 6. Epigastric pain

1,2,4,5

Which signs/symptoms would lead a nurse to suspect Fifth disease in a child brought into a pediatric clinic? 1. Erythema on the cheeks. 2. Joint pain. 3. Temperature 102°F (38.88°C). 4. Swollen knees. 5. Pruritic rash on soles of feet.

1,2,4,5

The nurse is to administer a client's first dose of lithium. Prior to giving the medication, the nurse should verify that what tests have been completed? 1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 3. Electroencephalogram (EEG) 4. Alanine Aminotransferase (ALT) 5. Electrocardiogram (ECG)

1,2,5

What physical changes should the nurse discuss with a client who is entering menopause? 1. Loss of bone density 2. Loss of muscle mass 3. Improved skin elasticity 4. A reduction in waist size 5. Increased fat tissue

1,2,5

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound 5. Use sterile forceps when cleaning the wound.

1,2,5

What clients could safely be delegated to the LPN/VN? 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1,2,5,6

Following a large hurricane, multiple clients arrive at the emergency room for treatment. The charge nurse must triage and assign clients to appropriate staff. Which clients could be assigned to an LPN? 1. Child with superficial burns on both upper arms. 2. Adolescent with bruising to left upper quadrant. 3. Crying toddler missing both upper front teeth. 4. Adult reporting headache and blurred vision. 5. Elderly adult reporting nausea and heartburn.

1,3

The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.

1,3

A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs

1,3,4,5

A confused client falls out of bed. When the nurse arrives, the side rails are up, the client has urinated on the floor, and an abrasion is noted on the client's forehead. Which information should be included in the incident report? 1. Abrasion on the client's forehead 2. Nurse's perspective as to how the client fell 3. Client's confused state 4. Presence of urine on the floor 5. Side rails were up

1,3,4,5

A nurse is educating the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? 1. Serve meal in a quiet environment 2. Give 30 minutes to eat 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

1,3,4,5

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1,3,4,6

The nurse, caring for a client diagnosed with Alzheimer's Disease (AD), notices the client becoming agitated. What nursing strategies would be appropriate for the nurse to initiate? 1. Provide a snack for the client. 2. Tell the client to stop the unwanted behavior. 3. Take client for a walk. 4. Ask the client to sweep the floor. 5. Inform the client that restraints will be used if behavior continues. 6. Turn on the client's favorite music.

1,3,4,6

The nurse is caring for a client with a colostomy who is experiencing excess flatulence. Which instructions should the nurse provide the client? 1. Limit intake of carbonated beverages. 2. Encourage fluid intake of 1000 mL/24 hours. 3. Create a small hole in the colostomy stoma pouch. 4. Limit consumption of beans, onions, and broccoli. 5. Release the pouch clamp to release the gas in the colostomy pouch.

1,4,5

The nurse is caring for a client on the cardiac unit. Which assessments are most important for the nurse to perform prior to the administration of diltiazem? 1. Note the rate and character of the apical pulse. 2. Ausculate the anterior and posterior breath sounds. 3. Check the morning results of serum calcium. 4. Review the last 24 hour urine output. 5. Monitor blood pressure. 6. Assess for chest pain.

1,5,6

The nurse has been working with an attractive teenage girl regarding appropriate nutrition. Which statement by the teenager would support a disturbed body image and the need for education on adequate nutrition? 1. "I am happy my weight is within normal limits. " 2. "I can never exercise enough to lose those saddle bags." 3. "I can always work a little harder on school work and hobbies." 4. "I try to eat only two meals a day to keep my weight down." 5. "I have been trying to include more fruits and vegetables in my diet."

2,3,4

A nurse is participating in a cancer risk screening program. Which signs/symptoms would indicate to the nurse that a client needs further investigation? 1. Unexplained weight gain of 10 pounds 2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating

2,3,4,5

A nurse, who has been assigned to the Emergency Response Team, is beginning to work on the agency's disaster response plan. What would be the nurse's role in this disaster response plan? 1. Perform duties specific to the area of expertise only. 2. Identify the individual in charge of a given client area. 3. Remain alert to potential security issues. 4. Consider ethical conflicts that may impact care. 5. Provide emotional support and make referrals to mental health resources.

2,3,4,5

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? 1. When sitting, keep knees slightly lower than the hips. 2. Avoid movements that require spinal flexion with straight legs. 3. Squarely face the direction of anticipated movement. 4. Pivot to turn while holding an object. 5. Wear comfortable, low-heeled shoes.

2,3,4,5

A client diagnosed with primary pulmonary hypertension is admitted to the hospital. What does the nurse expect the client to mention when reviewing the client's current treatment regimen? 1. Aminoglycosides 2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators

2,3,4,5,6

The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus

2,4,5

A child diagnosed with gastroenteritis is being given fluids in the emergency room for severe dehydration. Prior to discharge, the nurse instructs the mother how to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child? 1. Raisins 2. Bananas 3. Apples 4. Toast 5. Rice 6. Tea

2,4,5,6

What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

2,4,5,6

The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. The client asks the nurse to clarify foods that can be eaten with ulcerative colitis. What foods should the nurse suggest? 1. Dried beans 2. Fish 3. Apples 4. Yogurt 5. Scrambled eggs

2,5

What characteristics would indicate to the obstetrical nurse that a client is experiencing false labor? 1. Cervical dilation noted. 2. Contractions decrease with sleep. 3. Bloody show noted. 4. Contraction intensity increases with walking. 5. Contractions felt in abdomen above umbilicus.

2,5

What developmental milestone does the nurse expect to see in a two month old baby? 1. Responds to own name. 2. Holds head up. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Turns head towards sound. 6. Reaches for toy with one hand.

2,5

A female client has used medroxyprogesterone acetate injections for birth control for several years. For the past 6 months, attempts to become pregnant have been unsuccessful. What instruction should the nurse provide to the client? 1. Be seen in the fertility clinic by a primary healthcare provider who specializes in this problem. 2. Have a sperm count performed on the client's partner. 3. Be aware that ovulation may not occur for many months after using medroxyprogesterone acetate. 4. Ensure proper nutrition, rest, and establish an exercise program.

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the charge nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information, what should the charge nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assign the float nurse to the least acute clients. 3. Notify the nursing supervisor of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information,what should the nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assist the float nurse with the clients case. 3. Notify the charge nurse of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? Exhibit 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis

A nurse is caring for a client injured in a motor vehicle accident while driving intoxicated. After hearing that someone was critically injured because of the accident, the client mumbles, "But I only had just a few drinks". What is the most therapeutic statement the nurse could make to the client? 1. "If you only had a few drinks, how did you wreck?" 2. "What do you mean by 'just a few drinks'?" 3. "Tell me what you remember about the accident." 4. "You were driving when the accident happened."

A nurse is providing discharge teaching to a client who has had a cystectomy and formation of an ileal conduit. What client statement indicates that teaching was successful? Exhibit 1. I should restrict my fluid intake to decrease the need to empty the drainage bag. 2. I will change my appliance daily to prevent skin excoriation from the leakage of urine. 3. I will change my drainage bag whenever it is leaking, giving special attention to my skin around the bag. 4. I will restrict going to events outside the home because leakage is common and embarrassing.

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the coroner that the family is Jewish. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.

Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

The labor nurse is assessing a client admitted in preterm labor. Which client finding would require a social service consult? 1. Very quiet and avoids eye contact. 2. Reports that she is not married. 3. Has injuries in various stages of healing. 4. Reports frequent arguments with her partner.

The nurse discovers that a client diagnosed with severe depression formerly taught art classes at a local school. The nurse offers to obtain needed supplies if the client would instruct a few interested clients on simple painting techniques. The nurse is aware this type of intervention may help the client achieve what outcome? 1. Distract client from depressive thoughts of hopelessness. 2. Encourage client to begin communicating with others. 3. Utilize client's own strengths to increase self-esteem. 4. Establish the trusting nurse/client relationship.

The nurse has received the change-of-shift report. What client should the nurse assess first? 1. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. A client diagnosed with rheumatoid arthritis needing discharge teaching. 3. A client with a fractured right humerus who reports the cast is too tight. 4. A client with an above the knee amputation reporting phantom pain.

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3 - 4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times per week." 4. "I drink 64 ounces (1.89 L) of liquid per day."

The nurse is assessing the client's blood pressure using an electronic blood pressure machine and notes that the blood pressure reading is much higher than it has been since admission. The client denies history of hypertension. What action should the nurse take? 1. Call the primary healthcare provider and report the elevated blood pressure. 2. Check the blood pressure again in 4 hours and compare to the current blood pressure. 3. Re-check the blood pressure using a manual blood pressure cuff. 4. Call the nursing supervisor and prepare for a possible hypertensive emergency.

The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority assessment? 1. Measure the abdominal girth. 2. Administer pain medication. 3. Auscultate the lungs every 2 hours. 4. Inspect the burn for infection.

The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's most important intervention during the treatment? 1. Monitor vital signs and cardiac functioning. 2. Provide support to the client's arms and legs. 3. Provide suctioning as needed. 4. Place electrodes on temples.

The nurse is helping a UAP transfer a bed-fast client from a litter into the bed. What is the nurse's priority action? 1. Verify the client's identity band is correct. 2. Pull curtain to protect the client's privacy. 3. Lock wheels on both the litter and the bed. 4. Use a transfer board to move client safely.

The nurse is talking to the parents of a 4 year old who is suspected to have iron deficiency anemia. What statement by the parents would suggest the cause of this anemia to the nurse? 1. "Breakfast consists of iron fortified cereal most days." 2. "A typical lunch would be a chicken sandwich with orange slices." 3. "Our child drinks 30 ounces (887 mL) of milk a day." 4. "It is difficult to get our child to eat broccoli."

The nurse is teaching crutch walking to a client with a fractured lower leg with a non weight bearing cast. Which crutch gait would be most appropriate for the nurse to teach? 1. Swing through 2. Two point 3. Three point 4. Four point alternating

The nurse is to administer a fluid bolus to a 25 pound (11.36 kg) child. The primary healthcare provider prescribes a bolus of 20 mL/kg. What should the nurse administer? 1. 500 mL isotonic solution 2. 500 mL hypotonic solution 3. 227 mL isotonic solution 4. 227 mL hypotonic solution

The nurse is working on an in-patient psychiatric unit. The nursing care plan includes teaching a client about assertiveness. The client has a long history of being manipulated by the employer and spouse. What is the best rationale for including assertiveness training in this client's treatment plan? 1. All clients should have assertiveness skills. 2. The client has low self-esteem. 3. The client is being taught self-advocacy. 4. No client deserves to be manipulated by an employer.

The nurse just received an arterial blood gas (ABG) report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? 1. Tell the client to breathe faster. 2. Medicate for pain and ambulate. 3. Have client use the incentive spirometer. 4. Prepare to administer bicarbonate to buffer.

The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.

What intervention should the nurse take when providing oral care for the unconscious client? 1. Brush teeth with a stiff toothbrush. 2. Use thumb and index finger to hold the client's mouth open while brushing teeth. 3. Position the client on their side. 4. Rinse by injecting water into the center of client's mouth.

What is the most effective method of stroke prevention that the nurse should teach to the public? 1. Administering platelet inhibitors to prevent clot formation. 2. Undergoing transluminal angioplasty to open a stenosed artery and improve blood flow. 3. Maintaining normal weight, exercising, and controlling comorbid conditions. 4. Administering tissue plasminogen activator (tPA).

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

Which activity by the unlicensed assisted personnel (UAP) assisting a client with Parkinson's disease would require intervention by the nurse? 1. Assisting the client with ambulating to the bathroom and back to bed 2. Reminding the client not to look down while walking 3. Performing bathing and oral care for the client 4. Encouraging the client to feed self

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

Which response by the nurse is appropriate when responding to a client who reports eliminating all dairy foods from their diet because of lactose intolerance? 1. "Take calcium tablets since they can be used as a total supplement for dairy products." 2. "You can take lactose enzymes which will eliminate the effects of lactose intolerance." 3. "Valuable nutrients found in milk include calcium and protein." 4. "Consume more leafy green vegetables to maintain calcium levels."

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.

While preparing an IV in the med room, you observe a new nurse drawing up a dose of insulin in a tuberculin syringe. What is your priority action? 1. Report the incident immediately to the charge nurse. 2. Tell new nurse you will prepare and give the insulin dose. 3. Discuss procedure to prepare insulin with the new nurse. 4. Draw up insulin but let new nurse administer the injection.

While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.

A client who has been prescribed zolpidem for insomnia has received medication education. Which statement by the client indicates to the nurse that education was successful? 1. "There is a high potential for tolerance with this medication." 2. "I may do things in my sleep that I will not remember the next day." 3. "Daytime drowsiness is rare when taking this medication." 4. "The most common side effects of this medication are confusion and a bitter aftertaste."

A distraught client arrives at a mental health crisis center following a house fire that also took the life of a young family member. The nurse knows what action is most important when initiating crisis intervention for this client? 1. Assist the client to verbalize feelings of grief. 2. Assess client for any suicidal behaviors. 3. Admit client to general mental health unit. 4. Assign client to a grief counseling group.

A home care nurse is making an initial visit to an elderly client recently discharged following hip surgery. When evaluating the home environment, what environmental hazard is most concerning to the nurse? 1. Lamp plugged into extension cord. 2. Throw rugs on kitchen tile floor. 3. Gas fireplace in the living room. 4. Non-working wall socket in hall.

A pediatric nurse notes a "chubby" toddler who is pale. According to the parent, the toddler is easily fatigued. Based on this data, what initial question should the nurse ask the parent? 1. "How much weight has your child gained in the past month?" 2. "How much milk does your toddler drink in a day?" 3. "How many hours does your toddler sleep within a 24 hour period?" 4. "Do you give your child vitamins every day?"

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

An Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? 1. Have the family member repeat the nurse's explanation to the client. 2. Contact Social Services to find an authorized interpreter. 3. Use simple hand motions to explain the procedure to the client. 4. Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen.

During a physical assessment of a client who was started on haloperidol 5 days ago, the nurse notes restlessness, muscle weakness, drooling, and a shuffling gait. What should be the nurse's first action? 1. Hold the next haloperidol dose. 2. Administer the prn benztropine mesylate. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Draw a blood sample for drug level.

Several clients have reported to the charge nurse that they are not receiving pain relief when a certain RN administers their pain medication. The charge nurse has noticed that the RN has been looking unkempt in appearance and seems to be in a daze much of the time. What is the most appropriate action for the charge nurse to take? 1. Lessen the nurse's client assignment to see if things improve. 2. Discuss the concerns directly with the nurse. 3. Give the nurse a 6 month period to be observed. 4. Avoid confronting the nurse so that the client's care will not be jeopardized.

The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Which response by the LPN is appropriate in response to the inappropriate delegation? 1. Notify the primary healthcare provider. 2. Refuse the delegated intervention. 3. Discuss the assignment with another LPN. 4. Ask the charge nurse to evaluate the intervention.

The charge nurse is observing a new LPN preparing to irrigate a client's indwelling urinary catheter. The nurse must intervene when the LPN initiates what action? 1. Gathers all sterile equipment for procedure. 2. Opens bottle of sterile distilled water to flush. 3. Allows return flow to be achieved by gravity. 4. Uses gentle pressure when flushing catheter.

The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? 1. Request that the emergency department hold the client until one of the RNs is available to do the initial assessment. 2. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. 3. Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client. 4. Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible.

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.

The nurse has been working on a health plan promoting increased physical activity for a sedentary client. Which client outcome would indicate that the interventions were successful? 1. Walks 10 minutes per day periodically. 2. Establishes a routine of 30 minutes of brisk walking three days per week. 3. Reports there is not enough time for exercise. 4. Reports walking daily for about two weeks out of the last three months.

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks

The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of codependent behavior? 1. "I frequently tell my spuse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."

The nurse is teaching a group of high school students about car accident prevention. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom. 4. Female students who drive to weekly football games.

The nursing supervisor of a long-term care facility is planning to update emergency response plans for the large dementia unit. Staff has been asked to submit suggestions or concerns regarding current evacuation protocols which may need updated. The nursing supervisor is aware what exit procedure would be least helpful during an emergency evacuation? 1. All clients should be assisted to a central staging area. 2. Ambulatory clients should be directed to nearest exit. 3. Staff must visually check rooms to verify clients exited. 4. Clients exiting upper floors must use stairs, not elevator.

What would be most important for the nurse to teach parents in order to promote sleep and rest in the preschool child? 1. Allow the child to choose own bedtime based on degree of fatigue. 2. Develop a consistent routine before going to bed. 3. Assess how much sleep the child requires. 4. Set a consistent wake-up schedule.

When caring for a client on extended bedrest, which intervention should the nurse implement to decrease the risk of contractures? 1. Use a large pillow to support the head and shoulders. 2. Properly reposition every 2 hours. 3. Use a knee gatch to place knees at a 30 degree angle. 4. Place a trochanter roll along the inner aspect of each thigh.

Which prescription should the nurse question when a client is receiving spironolactone 25 mg by mouth daily? 1. Digoxin 0.125 mg by IVP daily 2. Potassium chloride 40 mEq orally t.i.d. 3. Cimetadine 200 mg IVPB q6h 4. Metoprolol 100 mg p.o. daily

Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes.

While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to a keep-open rate and obtain a replacement pump.

Where should a nurse place the stethoscope when auscultating heart sounds? 1. First intercostal space left of the sternum to hear sounds from the pulmonic valve area. 2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. 4. Fifth intercostal space left side of sternum to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

2,3

The RN is reviewing client assignments with the LPN working on a medical floor. Which clinical assignment would be appropriate for the LPN? 1. The client with nausea, vomiting, and mild metabolic alkalosis 2. The client with chronic back pain admitted for pain management 3. The client waiting to go to surgery for a scheduled total knee replacement 4. The client with a stage 3 decubitus ulcer requiring a dressing change 5. The client newly diagnosed with Guillain Barre' syndrome

2,3,4

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement? 1. "I should never eat fresh salad in a restaurant." 2. "I must wait two years before traveling abroad." 3. "I will need blood work once a month for a year." 4. "I will be able to donate blood when I am well."

A client performed a home pregnancy test and received a positive result. She arrives at the clinic for her first prenatal visit. She reports to the nurse that her last menstrual cycle was December 26, 2019. Based on the Naegele's Rule, when is the estimated date of confinement (EDC)? 1. September 3, 2020 2. September 26, 2020 3. October 2, 2020 4. October 3, 2020

A client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? 1. "Don't worry, it's a very simple procedure." 2. "You have already signed the consent form." 3. "I will tell the doctor you need to talk more." 4. "Can you tell me what most concerns you?"

A client taking phenelzine is admitted to the hospital. Which healthcare provider prescription should the nurse question? 1. Take blood pressure lying, sitting, and standing once per shift. 2. Order a complete blood count and liver profile studies. 3. Eliminate foods containing tyramine from diet. 4. Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime.

A client with diabetes is hospitalized for debridement of a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's priority action? 1. Notify the primary healthcare provider. 2. Apply a vest restraint as requested by family. 3. Move client to a room near the nurse's desk. 4. Obtain a finger-stick blood glucose level.

A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to have the dietician talk with the client about food preferences. 3. Notify the case manager to arrange a meeting with the client's family . 4. Provide additional information as requested by the client concerning nourishment.

A nurse has received morning report on multiple clients. What client should the nurse assess first? 1. Client on 2/L min, of oxygen by nasal cannula with pneumonia. 2. Client with Crohn's disease reporting two semi-loose stools. 3. Client one day post-appendectomy reporting abdominal cramps. 4. Client on heparin drip reporting bleeding gums when brushing teeth.

A tour bus is involved in an accident, sending several clients to the emergency room for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the E.R. narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1. Call the pharmacy to prepare the drug. 2. Repeat the prescription back to the primary healthcare provider. 3. Ask the primary healthcare provider to spell the drug name for clarification. 4. Inform the healthcare provider that this medication requires a written prescription.

An elderly homeless client is brought to the emergency room for evaluation following a fall. What assessment findings by the nurse should be reported immediately to the primary healthcare provider for further evaluation? 1. The client is unsteady when walking to the bathroom. 2. The client cannot state day, date or present location. 3. The client refuses to remove either shoes or socks. 4. The client has loss of sensation below the left knee.

An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the RN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker with a fixed rate of 70 beats/minute. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher."

The nurse is assessing an adolescent newly diagnosed with obsessive compulsive disorder (OCD). The client is nervously rearranging papers on the desk and stating "why can't I stop this?" What would be the most therapeutic response(s) by the nurse at this time? 1. "We can help you control impulses, but you will never be cured." 2. "You will feel much better after beginning your family therapy." 3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."

3,4,5

Which clients would the nurse monitor for the development of hypovolemic shock? 1. Having an allergic reaction form multiple wasp stings 2. Post-operative cervical spinal cord surgery 3. Addisonian crisis 4. Partial thickness burns over 50% total body surface area (TBSA) 5. Type 2 diabetic with hyperglycemic hyperosmolar nonketotic coma (HHNK)

3,4,5

What information should the nurse include when providing community teaching on burn prevention strategies? 1. Have chimney professionally inspected every 5 years. 2. Microwave a baby bottle rather than heating on the stove. 3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

3,4,5,6

The nurse is discharging a client post right radial percutaneous transluminal coronarey angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? 1. Do not use the wrist to lift more than 5 pounds (2.27 kg) for 24 hours. 2. Stop taking aspirin in one week. 3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 5. Do not shower or soak in a tub for one week. 6. Take short walks around your house.

3,4,6

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

3,5

The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers

The nurse is bathing a confused client in the acute care unit. The nurse talks with the client and explains each procedure. During the bath, the client becomes very agitated. What should the nurse do? 1. Complete the bath as quickly as possible. 2. Reassure the client and request them to stop acting out. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, dress and reassure the client.

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? 1. Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client assessment findings.

The nurse is developing the plan of care for a newly admitted client diagnosed with schizophrenia. What goal would the nurse consider a priority for this client? 1. Schedule alone time for client to relax. 2. Frequently reorient the client to surroundings. 3. Encourage participation in all social activities. 4. Assign same staff to provide client care daily.

The nurse is talking with several high school students after a classmate from their school died in a motor vehicular accident. Which statement by the nurse is therapeutic? 1. "Sometimes bad things happen to people we care about." 2. "I was so upset that the student who died had been drinking." 3. "Why are you angry? Tell me how you feel about losing your friend." 4. "What would you like to talk about concerning the loss of your classmate?"

Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler? 1. "It is important to give my child low fat milk after one year of age". 2. "If the child won't eat new foods after three tries, he is not going to eat it". 3. "I think that the sooner one starts to give vitamins to children, the better". 4. "I try to provide whole grains, fruits, vegetables, and meat daily".

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? 1. Sit with the client during meals and encourage the client to eat all foods on the tray. 2. Assess the client's food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high-protein, high calorie snacks to the client between meals.

Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.

Which prevention strategy should the nurse consider when developing a health promotion plan for new parents concerning sudden infant death syndrome (SIDS)? 1. Place the infant in the prone position when placing the infant in the bed. 2. The child should sleep in a separate room from the parents. 3. The child should not have a pacifier in place when sleeping. 4. The child should be placed in the supine position when sleeping.

Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche

Which statement by a client would indicate to the nurse that education about alendronate has been successful? 1. "It is recommended that I recline for 15 minutes after taking my medication." 2. "Food should be eaten immediately after taking alendronate." 3. "My medication tablet should be chewed for rapid absorption." 4. "I should drink a full 8 ounce glass of water with my medication."

A client on routine dialysis asks the nurse about the process of a family member donating a kidney. In what order should the nurse explain the steps for kidney organ donation? The donor and recipient will undergo tissue typing and antibody screening. The donor will undergo a psychosocial examination and counseling. The recipient and donor will be assessed and treated for any dental caries. The recipient will undergo hemodialysis. The recipient will receive immunosuppressive agents.

This is the correct order

A nurse is reviewing the lab values for a group of clients in a psychiatric emergency department. Rank each lab result from greatest to least concern to the nurse. The client diagnosed with schizoaffective disorder who has a potassium level of 7.0 mEq/L (7 mmol/L) The client diagnosed with schizophrenia who is taking clozapine and has a WBC count of < 3000 mm³ (3 x 10^9/L) The client diagnosed with bipolar disorder who has a lithium level of 1.3 mEq/L. The client admitted with a blood alcohol level of 0.08% (80 mg/dL)

This is the correct order

In what order should the emergency department triage nurse send these clients to a room for treatment? Place in priority order. Client who has multiple injuries from a motor vehicle accident. Elderly client who fell and fractured the left femoral neck. Female client stating she has been raped. Client reporting epigastric pain and nausea after eating.

This is the correct order

In what order will the nurse provide instructions to a client on using a cane? With cane on stronger side of body, support body weight with both legs. Move cane forward 6-10 inches (15 - 25 cm). Advance weaker leg forward toward the cane. Advance stronger leg forward toward cane.

This is the correct order

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. In a position of comfort 4. In a dependent position

The nurse is assessing a client who was admitted to the inpatient psychiatric unit five days ago for exacerbation of psychotic symptoms, as evidenced by delusions of grandeur. Which type of client remarks indicate continued delusions of grandeur? 1. Comments with fear as a theme. 2. Comments with a theme of being grand or powerful. 3. Comments related to missing body organs. 4. Comments related to being under someone else's control.

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? 1. The client is probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care.

The primary healthcare provider (PHP) informs a client that cancer was identified in the large intestine, and surgery should be scheduled as soon as possible. After the PHP leaves the room, the client turns their head away from the nurse and begins to cry. Which action by the nurse is appropriate? 1. Exit the room quietly. 2. Touch the client's shoulder. 3. Notify the client's family. 4. Begin preoperative instruction.

The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications? 1. Neck dressing intact, clean and dry 2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 4. Vocal quality weak and clear 5. Left-sided cheek twitching

2,3,5

Which nursing action would be appropriate to assign to the LPN working at an HIV/AIDS hospice setting? 1. Assessing for signs of secondary opportunistic infections. 2. Collecting data regarding response to pain medications. 3. Teaching the UAP about nutritional needs of HIV/AIDS clients. 4. Assisting clients with personal hygiene needs.

The nurse is teaching a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that teaching has been successful? 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."

2,3,5

The nurse is making an initial homecare visit to a client following a stroke. The client has right arm weakness and a limp in the right leg. While evaluating the client's ability to prepare food, the nurse is most concerned about what actions? 1. Uses skid-proof shoes when walking in kitchen. 2. Pours boiling water from pan into cup of tea. 3. Heats food in microwave instead of the oven. 4. Uses electric chopper to dice up vegetables. 5. Prepares and cooks large casserole in oven.

2,5

A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate? 1. "Calm down first, and then I will call your therapist." 2. "It's against the rules to call in the middle of the night." 3. "You must be distressed to want to talk at this late hour." 4. "That's a valid request, but it must wait until morning."

A client admitted to the Coronary Care Unit (CCU) following a myocardial infarction (MI) expresses fear of the equipment and noise in the busy unit. What is the most therapeutic response by the nurse? 1. "Everyone gets scared here at first." 2. "Why are you afraid of equipment?" 3. "This all seems frightening to you." 4. "You won't have to be here very long."

Which initial arterial blood gas (ABG) results would the nurse expect on a client who has overdosed on aspirin (ASA)? 1. pH 7.54, PaCO2 41, PaO2 63, SaO2 91, HCO3 36 2. pH 7.24, PaCO2 37, PaO2 83, SaO2 95, HCO3 18 3. pH 7.49, PaCO2 30, PaO2 88, SaO2 92, HCO3 25 4. pH 7.12, PaCO2 28, PaO2 72, SaO2 93, HCO3 10

Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake

A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate? 1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records?

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to obtain clients vital signs and a weight. 2. Assign an LPN/VN to perform the initial nursing history and physical assessment. 3. Have an LPN/VN perform collect data on the client and report results to RN. 4. Inform one of the RNs that a new client is on the floor and that a nursing history should be completed as soon as possible.

A client arrives on the orthopedic unit following an open reduction-internal fixation (ORIF) of a fractured femur. Following the initial assessment, the nurse offers pain medication. The client refuses, indicating a preference to control personal pain with meditation. What observations by the nurse would indicate this method has been successful in controlling the client's post-op pain? 1. Client shuts eyes tight when leg repositioned. 2. Client is restless and makes facial grimaces. 3. Client vitals are at baseline during activity. 4. Client is able to sleep through the night.

Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism? 1. Steroids 2. Anticonvulsants 3. Beta blockers 4. Iodine compounds

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse initiate? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water

The nurse is caring for a client on the psychiatric unit. The client is prescribed fluphenazine 10 mg. The drug is available as an elixir: 2.5 mg / 5 mL. How many mL will the nurse give to the client? ______mL. Round answer to the nearest whole number.

A 12 year old female, with a history of juvenile rheumatoid arthritis, is being admitted for re-evaluation. The child reported these symptoms for the last week: temperature of 102.9ºF/39.4ºC at 4:00 pm every day, increased pain in joints, loss of appetite, and fatigue. What would be an appropriate room assignment by the charge nurse? 1. Private room only. 2. Rooming with a 12 year old male in skeletal traction due to a fractured femur. 3. Rooming with a 10 year old female that has been admitted for sickle cell disease. 4. Rooming with a 14 month old female that has been admitted for orthopedic surgery.

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

A client is admitted to the hospital at 36 weeks gestation with a diagnosis of placental abruption. Following an initial assessment, what action by the nurse is most important? Exhibit 1. Apply the fetal monitor. 2. Complete an abdominal prep. 3. Insert large bore intravenous line. 4. Have client sign the consent form.

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Midabdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea

A recently hired nurse is distressed that the facility's documentation system has been upgraded to a more challenging process, including the use of laptops in client rooms. The new nurse expresses concerns to the nurse manager, indicating an inability to learn the new process. What comment by the nurse manager is most appropriate? 1. "Of course you can do this, and I will help you! " 2. "Why does this new system upset you so much?" 3. "It is hard to deal with so many changes at once." 4. "This is so easy, even a child can learn how to do it."

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

Which nursing intervention will be most helpful to a middle-aged client experiencing insomnia? 1. Instruct the client to initiate an exercise routine during the day. 2. Educate the client on ways to adjust the sleep environment. 3. Instruct the client on progressive relaxation techniques to be used just before bedtime. 4. Instruct the client to decrease caffeine intake.

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."

A client arrives at the crisis center and reports stopping daily lithium because of pregnancy. What response by the nurse is most accurate? 1. "Are you positive that you are actually pregnant?" 2. "Lithium is perfectly safe throughout pregnancy." 3. "The psychiatrist can change you to another medication that is safe." 4. "It may be worse to suddenly stop the medication than to take the medication."

A client arrives at the emergency room with chest pain, dyspnea and diaphoresis, stating "I think I am going to die." What would be the most appropriate comment by the nurse? 1. "We will do everything we can for you." 2. "Would you like me to call your family?" 3. "What makes you think you are going to die?" 4. "Have you ever had these symptoms before?"

A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? 1. Cancel physical therapy and allow client to leave. 2. Ask client to stand with crutches to check the size. 3. Tell client insurance will not permit use of old crutches. 4. Send client with crutches to physical therapy for evaluation.

A client being treated for major depressive disorder arrives at group therapy for the first time in a week wearing clean clothes after showering. What response by the nurse would be therapeutic? 1. "Why are you all dressed up for group?" 2. "Maybe you could add makeup tomorrow." 3. "You must feel better after finally showering." 4. "You look really nice in that flowered jacket."

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms

A client has been started on intravenous gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for the client? 1. BUN and creatinine. 2. Liver function studies. 3. Hemoglobin and hematocrit. 4. Peak and trough levels.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

A client is awake in the recovery room following a cardiac catheterization performed through the left radial artery. During the assessment, the nurse notes severe swelling of the left upper arm with a diminished left radial pulse, indicating an internal arterial hemorrhage. The cardiologist states the client will require immediate surgery to repair the leaking artery. The nurse understands what fact about the current consent form? 1. Can be assumed since it's an emergent situation. 2. Should be signed by client who is currently awake. 3. Is not needed since client consented to catheterization. 4. Must be approved by family or a spouse.

A 20 year old client has been admitted to the hospital with a diagnosis of preeclampsia. The charge nurse has only semiprivate rooms available. What roommate would be most appropriate for this client who is being admitted? 1. An adolescent primigravida with many visitors. 2. A 25 year old post induction for fetal demise. 3. A 35 year old awaiting discharge after a total abdominal hysterectomy (TAH). 4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.

A client who is being evaluated for a recent head injury requests hydrocodone with acetaminophen for a headache. What response by the nurse is most appropriate? 1. "A hydrocodone and salicylate combination would probably provide better relief." 2. "Due to the impact that your head received, the healtcare provider may want to order a narcotic to be given intravenously for a more rapid relief." 3. "Acetaminophen is not recommended for clients with head injuries, but I can ask for a substitution." 4. "Hydrocodone is an opioid which is usually avoided because it could cause drowsiness and possibly prevent recognition of a worsening condition."

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial line BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

A client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what to the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.

A client who was admitted to coronary care unit with a diagnosis of myocardial infarction is on continuous cardiac monitoring. Which cardiac change noted on the monitor would be of greatest concern? 1. Ventricular tachycardia > 100 bpm 2. Atrial fibrillation with atrial rate > 300 per minute 3. Four premature ventricular contractions within one minute 4. ST segment depression of 0.5 mm

A non-English speaking client arrives in the emergency room with a 2 inch head laceration. The nurse attempts to complete the assessment but is unable to understand information provided by client or family. The facility interpreter lives several hours away; however, a UAP is available and willing to help translate. The nurse should be most concerned about what situation? 1. The UAP is not trained to interpret medical terminology for a client. 2. The facility translator is best qualified, but waiting causes delay of treatment. 3. Obtaining consent through an unofficial interpreter is not considered legal. 4. The UAP is not providing direct care, which violates HIPAA privacy regulations.

The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? Exhibit 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

The school nurse has educated a group of teens concerned about acquiring the Ebola virus. Which statement by the students would indicate to the nurse that further teaching is necessary? 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."

Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.

Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions

The nurse is participating in a presentation regarding adolescent violence to middle and high school faculty and staff. What risk factors for violence should the nurse include? 1. Attention deficit disorder 2. Diminished economic opportunities 3. Authoritative parenting style 4. Active in school sports 5. High parental involvement

1,2

A client has been admitted to the unit with acute pyelonephritis. What interventions should the nurse include in this client's plan of care? 1. Observe for changes in mental status. 2. Assist client to restroom. 3. Monitor temperature every 4 hours. 4. Help the client get in a comfortable position to void. 5. Instruct client to void every 30 minutes while ill.

1,2,3,4

The nurse is monitoring the infection risk in a client that is to begin chemotherapy. Which activity should alert the nurse that the client is at a higher risk for infection? 1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 4. Selects steamed vegetables as part of routine dietary intake. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.

1,2,3,5,6

A school nurse is planning a lesson on inhalant abuse for a high school health class. Which information does the nurse need to include? 1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 3. Although inhaling can make a person very ill, death is highly unlikely. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure. 5. Inhalants cause the heart to beat slowly.

1,2,4

Which client would be appropriate for the RN to assign to the LPN? 1. Client with cast to right leg requiring pain medication. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client one day post kidney transplant. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 5. Client prescribed antibiotics for cystitis.

1,2,4,5

Which food items, if chosen by a client diagnosed with diverticulosis, would indicate to the nurse that the client understands the prescribed diet? 1. Avocados 2. Acorn squash 3. Applesauce 4. Lima beans 5. Raspberries 6. Cottage cheese

1,2,4,5

The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? 5. Can the family take turns in managing the mother's sleep problems?

1,3,4

The nurse is assessing a newborn to determine gestational age. What findings by the nurse would indicate the infant is premature? 1. Folded ear pinna springs back slowly. 2. Peripheral cyanosis on feet and hands. 3. Shoulders and chest have moderate lanugo. 4. Vernix covering axilla, back and buttocks. 5. Feet soles entirely covered with creases.

1,3,4

After assessing a client, the nurse determines that the client has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which interventions would the nurse include for this client? 1. Have client attempt to void again (double voiding). 2. Encourage the client to void every 8 hours. 3. Perform Credé method. 4. Have client listen to sound of running water. 5. Teach intermittent catheterization for retention, if needed.

1,3,4,5

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1,3,4,5

Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis? 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

1,3,4,5

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

1,3,4,5,6

A client arrives at the emergency room with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and life style with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? 1. A daily glass of white wine 2. Bacon and eggs on weekends 3. Smoking two cigars every day 4. One half liter of soda daily 5. Baked cod twice a week 6. A BMI of 31.5 kg/m2

1,4,5,6

The nurse is instructing the mother of a toddler diagnosed with cystic fibrosis (CF) about specific dietary modifications the child will need. The nurse knows the teaching is successful when the mother selects what foods? (Select All That Apply). 1. Potato chips 2. Low-fat yogurt 3. Salt-free bacon 4. Hot dog on a bun 5. Fresh avocados 6. Macaroni and cheese

1,4,5,6

A RN is observing an unlicensed nursing personnel (UAP) feed a client who is on aspiration precautions. Which action by the UAP would require the nurse to intervene? 1. Elevating the head of the bed to a 90 degree angle 2. Instructing the client to lean the head back slightly when swallowing. 3. Adding a thickening agent to liquids. 4. Feeding the client small amounts of food per bite.

A client admitted to the psychiatric unit is diagnosed with depression. What is the nurse's best response? 1. I understand what you are feeling. I have been left by someone I loved before. 2. You feel upset and unhappy by the loss of your significant other? It is ok to cry. 3. Don't worry. You will feel better once we start giving you medication for depression. 4. Crying isn't going to help anything. Let's talk about your past medical history now.

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

A client diagnosed with Addison's disease has been prescribed prednisolone. Which statement by the client indicates that the client's medication instructions for prednisolone have been effective? 1. "I should avoid foods high in protein." 2. "I will take prednisolone in the morning." 3. "I need to schedule an eye examination every 2 years." 4. "Infections will be reduced while taking prednisolone."

A client with asthma uses a corticoid inhaler. What teaching should the nurse provide to decrease the risk of an oral fungal infection? 1. Lessen the exposure of the oral mucosa to the ICS by exhaling rapidly. 2. Rinse the mouth completely and brush teeth following the use of the ICS. 3. Use alcohol based mouth rinses with ICS. 4. Drink water prior to using the ICS.

A client with diabetes has a history of ignoring the primary healthcare provider's prescription for daily medication management of the illness. The client has been working toward a health promotion goal of increased adherence to prescribed medication regimen. Which outcome suggests that the client has met the health promotion goal? 1. Client has lost five pounds. 2. Client takes medication as prescribed. 3. Client has been hospitalized twice for complications of diabetes. 4. Client walks one mile per day.

A female client arrives at the community health clinic seeking a form of contraceptive and tells the nurse that she really desires getting an intrauterine device (IUD). Following the assessment, the nurse realizes that the IUD would be contraindicated for this client. What factor would be an absolute contraindication for this client receiving an IUD? 1. History of irregular menstrual cycles 2. Ongoing pelvic infection 3. History of an ectopic pregnancy 4. Current fibrocystic breast disease

A nurse is caring for a multipara client in active labor who received morphine 4 mg IVP for pain. Thirty minutes later, the client had a precipitous delivery. What should the nurse prepare to administer to the newborn? 1. Oxygen 2. Naloxone 3. Glucose 4. Vitamin K

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. "I will soak my feet for 30 minutes a day." 2. "I will avoid using a heating pad on my feet." 3. "I can use scissors to remove the corns on my toes." 4. "I enjoy walking without my shoes around the house."

What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? 1. Eat a light breakfast two hours before the test. 2. Dress in loose, comfortable clothing. 3. Take nitroglycerin dose 15 minutes prior to test. 4. Limit drinks with caffeine to 8 ounces (240 mL) within 12 hours.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hands 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the entire cast prior to bathing 4. Elevating the casted leg on two pillows

The nurse overhears this client responding on the phone when their boss asks them to work an extra night shift. Which statement by the client demonstrates assertive communication? 1. "I know you are joking! I have already worked an extra night shift." 2. "I do not want to work an extra night shift. I have already worked an extra shift this week." 3. "Umm, well, okay. I guess I will work an extra night shift." 4. "Okay, I'll work an extra night shift." Then they say to another client. "The nerve of my boss to ask me to work another extra shift."

What statement by the nurse would be most appropriate for a client who is exhibiting signs of escalating anger? 1. "You seem angry, but I can't understand why you would be upset." 2. "I notice that you are angry. Please share what you are thinking." 3. "You need to calm down. You will make the other clients upset." 4. "I am not going to be able to talk to you if you keep getting angry like this."

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? 1. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 2. Use a new cotton ball for each cleansing wipe. 3. Instill artificial tears into the lower eye lids as prescribed. 4. Protect the eyes with a protective shield. 5. Monitor eyes for redness, and exudate.

2,3,4,5

What dietary information should the nurse provide to a client diagnosed with Celiac disease? 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2,3,4,5

A client who has Parkinson's disease has a new prescription for benztropine. What should the nurse include when teaching the client and spouse about this medication? 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. Notify your primary healthcare provider if you develop urinary retention. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up or stand up slowly to prevent lightheadedness.

2,3,5

A client with a long standing history of diabetes presents to the emergency department (ED) with a serum blood sugar of 400 mg/dL (22.19 mmol/L). What lab data for this client are consistent with diabetic ketoacidosis (DKA)? 1. Serum sodium 140 mEq/L 2. Ketonuria 3. Serum potassium 5.3 mEq/L 4. PaCO2 52 5. pH 7.30

2,3,5

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure? 1. "The stockings should be applied when my legs are swollen." 2. "I will apply the anti-embolism stockings before getting out of bed." 3. "I will apply cortisone-10 ointment to skin on both legs every day." 4. "Prior to applying the stockings, I will look for reddened areas on my skin." 5. "When pulling up the stockings, I will allow for an extra roll of the stocking at my calves."

2,4

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2,5

A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? 1. December 3 2. December 7 3. December 10 4. December 13

A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.

A nurse is preparing to administer an insulin infusion to a client. The nurse calculates the infusion pump setting as 9 mL/hr. What should the nurse do next? 1. Administer the calculated medication dosage. 2. Call the primary healthcare provider to clarify the dosage. 3. Ask another nurse to calculate the dosage. 4. Notify pharmacy of the pump setting for the calculated dosage.

After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a primary healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take? 1. Administer the insulin dose to the client. 2. Consult with the charge nurse about administering the insulin dose to the client. 3. Tell the nurse that whoever draws up the medication has to administer that medication. 4. Offer to take the call from the primary healthcare provider so the nurse can administer the insulin.

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The RN requests reassigning at least one of the clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of the clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN why the assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease? 1. Wear mask only. 2. There are no precautions necessary. 3. Standard precautions. 4. Limit interactions with client.

The nurse is caring for a client who is taking an antipsychotic medication for the treatment of schizophrenia. The nurse is told in report that the client has akathisia, as a side effect of their antipsychotic medication. What symptom should the nurse expect this client to have? 1. Upward gaze of the eyes. 2. Involuntary movement of the tongue. 3. Reports of restlessness. 4. Lack of movement or slowed movement.

The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

The nurse is planning a teaching session with the family members of a client diagnosed with moderate Alzheimer's disease. Which topic is most important for the nurse to discuss? 1. Encouraging dependence on family members 2. Performing passive range of motion 3. Providing a safe environment 4. Monitoring vital signs every 8 hours

The nurse is preparing to discharge four clients from the unit. Which client is most likely to warrant a referral to other agencies or community outreach programs? 1. 45 year-old client who had nasal surgery. 2. 50 year-old client postop mastectomy. 3. 72 year-old client with diabetes and obesity. 4. 80 year-old client with a diagnosis of delirium caused by dehydration.

What is the first intervention the emergency department (ED) nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning? 1. Torso warming 2. Start intravenous infusion 3. Administer oxygen 4. Prepare for nasogastric intubation

Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? 1. Reduction of anxiety 2. Referral to community resources 3. Identification of lifestyle changes 4. Verbalization of energy-conservation techniques

A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."

3,4,5

The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client? 1. Increased systolic BP 2. Hypokalemia 3. Bradycardia 4. Wheezing 5. Decreased hematemesis

3,4,5

A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful? 1. Teach the client to perform active facial exercises several times a day. 2. Provide a liquid diet high in protein and calories that will be easily swallowed. 3. Provide oral hygiene after eating. 4. Teach the client to chew food on the unaffected side of the mouth.

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.

A nurse is providing education to a client regarding the use of an inhaler for acute asthma symptoms. Which statement made by the client would indicate the need for further teaching? 1. "I should shake the inhaler well before use." 2. "I should breathe out slowly and completely through my mouth before placing the mouthpiece of the inhaler in my mouth." 3. "I should hold my breath for approximately 8-10 seconds before exhaling slowly." 4. "I should administer the two puffs that are ordered in rapid sequence.

A nurse is triaging a 2 year old child in the pediatric emergency department. The nurse notes that the child will not lie down and is consistently drooling. A croaking sound is heard on inspiration. What is the priority nursing intervention? 1. Examine the oral pharynx using a tongue depressor. 2. Administer a sedative so the child can be examined. 3. Have a second nurse hold the child down for the assessment. 4. Notify the primary healthcare provider immediately.

Following hip replacement surgery, an elderly client is being transferred to a long term care facility for therapy. What priority action by the nurse best promotes continuity of care for the client? 1. Explain future care requirements to the family. 2. Call facility's nurse manager to give oral report. 3. Discuss client's needs with healthcare provider. 4. Send written summary of client needs to facility.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.

The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. What action should the nurse implement first to ensure client safety? 1. Take report on the most critical clients first. 2. Encourage the staff to help each other. 3. Assign one additional client to each nurse. 4. Call the nursing supervisor to request additional staff immediately.

The nurse is preparing to initiate postmortem care. Which postmortem care interventions would the nurse implement? 1. Identify the client by the name on the client's armband. 2. Remove tubes and indwelling lines after cleansing the body. 3. Insert the dentures after the family has viewed the body. 4. Maintain body preparation according to the client's religious beliefs.

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

What instruction would the nurse give a client about a newly prescribed salmeterol inhaler? 1. "Use the inhaler immediately if wheezing and shortness of breath occur during exercise." 2. "Use the inhaler when you experience a stuffy nose due to seasonal allergies." 3. "Carry the inhaler with you at all times and take 2 puffs anytime you experience an exacerbation." 4. "This inhaler should be used routinely as prescribed even when free of symptoms."

The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.

4,5

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.

4,6

An unlicensed assistive personnel (UAP) is assisting a client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention by the nurse? 1. Holds chest drainage unit (CDU) at the level of the chest. 2. Disconnects the chest tube from suction. 3. Allows the client to ambulate. 4. Helps client use a walker.

Which independent nursing actions should the nurse initiate for a client admitted with heart failure? 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Evaluate urine output from diuretic therapy 4. Educate client regarding signs and symptoms of heart failure 5. Administer medications as prescribed

1,2,3,4

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1,2,4

The nurse has been teaching the client about warfarin for prevention of pulmonary emboli. Which comments by the client indicate understanding of the medication? 1. "I must get my blood levels checked regularly." 2. "I shouldn't change my diet to include a lot of foods containing vitamin K without supervision." 3. "I should eat lots of foods containing vitamin K." 4. "I should report this medication to any primary healthcare provider that I see." 5. "I should not change the dosage without talking with my primary healthcare provider."

1,2,4,5

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake? 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu

1,2,4,5

A client who needs to have a stool specimen for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid

1,3,4,5

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Empty the indwelling catheter on the four hour postop client. 2. Instruct a client to soak in a warm bath for 30 minutes when experiencing endometrial discomfort. 3. Monitor the peri-pad count on a client diagnosed with fibroid tumors. 4. Assist client two days post hysterectomy to the bathroom. 5. Encourage a client who is refusing to get out of bed to walk in the hall.

1,4,5

Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 1. Talk to each nurse about concerns related to assigned clients. 2. Call the family of a client suffering from dementia to discuss long term care placement. 3. Briefly assess every client. 4. Complete a client assignment sheet for the oncoming staff. 5. Receive report from the emergency department (ED) on a new client.

1,4,5

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

A right-handed client's intravenous (IV) infusion has infiltrated at the client's left dorsal metacarpal vein. The nurse would initially assess which vein to start another intravenous infusion? 1. Basilic vein 2. Cephalic vein 3. Median antecubital vein 4. Dorsal metacarpal vein

The nurse is teaching a client regarding herbal therapy. What is the main goal of herbal therapy? 1. To treat a specific disease or symptom by taking prescription medications. 2. To restore balance within the body by supporting the client's self-healing ability. 3. To avoid the use of toxic chemicals within the body. 4. To incorporate Eastern healing practices into Western medicine.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.

The nurse is working on health promotion plans for a small group of school-aged children who are at risk for obesity. Which baseline data would support the risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.

Donepezil has been prescribed to a client with cognitive impairment. Which statement by the family member indicates understanding of the nurse's instructions on this medication? 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.

The charge nurse is orienting a new nurse to the pediatric unit. Which teaching related to assessment is appropriate? 1. One assessment should be done daily on each client by the charge nurse. 2. An assessment should be done daily on each client at the beginning of the shift. 3. Assessments of clients should be updated as the nurse provides care to clients. 4. Assessments of clients should be done at the beginning of the shift and updated as nursing care is provided.

A nurse is in the mall when a shopper suddenly becomes non-responsive. Taking an available automatic external defibrillator (AED) from the wall, the nurse would immediately initiate interventions in what order? Turn on the AED machine. Uncover the client's chest. Place pads on client's torso. Await analysis of rhythm. Tell everyone to stand clear. Press the shock button.

This is the correct order

A client in a psychiatric unit tells the nurse, "I wanted to take the car to work, but the train station took all the tracks. Driving is the ticket when you want to go to the movies. No one needs money in heaven. We have money in our foods." How should the nurse document this conversation? 1. Associative looseness 2. Circumstantiality 3. Echopraxia 4. Anhedonia

What assessment data would a nurse expect to find in a client diagnosed with acute inflammatory bowel disease? 1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 mL/hr 5. Increased serum prealbumin

1,2,3,4

The nurse admits a child with a history of cystic fibrosis (CF) with vomiting for 3 days, headache, and unusual behavior. What does the nurse anticipate the lab values will show? 1. Hypernatremia 2. Hypercalcemia 3. Hypocalcemia 4. Hyponatremia

A nurse from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. Which clients would be appropriate for the charge nurse to assign to the nurse from the maternity unit? 1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus 5. Client newly admitted with Guillian-Barre Syndrome

1,2,3

Which response by the nurse is appropriate when admitting a 5 year old child who is crying and hugging a stuffed animal? 1. "Hello, I am your nurse. I am going to show you to your room." 2. "Don't cry. Let's go to the playroom where you can meet other children." 3. "You are upset. I see you have your stuffed animal." 4. "Can I hold your stuffed animal? Then, would you like to put your stuffed animal in the bed?"

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action? 1. Confront the nurse with the consequences of tardiness. 2. Ask the nurse to consent to a drug screening test. 3. Document the tardiness in the nurse's record. 4. Ask the nurse the reason for being tardy.

A term primipara is admitted in active labor and with rupture of membranes. Her last vaginal exam one hour ago revealed that she was dilated to 6 centimeters, 100% effaced, and at -1 station. The client calls out "My belly really hurts. I feel like I have to have a bowel movement!" Which action should the nurse perform first? 1. Offer her a bedpan. 2. Call the primary healthcare provider. 3. Prepare for epidural administration. 4. Perform a sterile vaginal exam.

A tour bus is involved in an accident, sending several clients to the emergency room (ER) for treatment. An unconscious client with multiple internal injuries requires immediate surgery. When itemizing the client's belongings, the nurse finds a wallet containing four thousand dollars. What is the appropriate method for the nurse to secure the money? 1. Place wallet inside client's pants and then in belongings bag. 2. Secure the money in an envelope in the ER narcotics drawer. 3. Sign money over to the hospital CEO until client is discharged. 4. Tally cash with 2nd nurse, document and lock in hospital safe.

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

The nurse is caring for a client admitted to rule out myocardial infarction. The nurse has administered sublingual nitroglycerin. What time frame should the nurse expect the earliest onset of effectiveness? 1. 15 seconds 2. 3 minutes 3. 5 minutes 4. 15 minutes

The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.

The nurse is caring for a client diagnosed with alcohol dependence who is prescribed a benzodiazepine. Which potential side effect of benzodiazepine has a higher priority for the nurse to monitor? 1. Sedation 2. Drowsiness 3. Drug dependence 4. Impaired coordination

At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.

A client has a prescription for nitroglycerin gr 1/400 SL prn for angina pain. How many tablets should the nurse give the client? Use numbers and decimals only. Exhibit

0.5

A client had a suspicious area of the skin biopsied and sent to the lab for analysis. The client states "I am worried that the pathology report will indicate cancer." Which response would the nurse initiate to assist the client in reducing their anxiety? 1. "You are anxious about the pathology report?" 2. "Would you like me to recommend a movie for you to watch?" 3. "I will notify your daughter that you are concerned about the pathology report." 4. "Have you tried taking long, slow deep breaths and not thinking negative thoughts?"

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? Exhibit 1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."

Which male client condition in the after-hours clinic should the nurse assess first? 1. Scrotal pain and edema. 2. Erection lasting for 2 hours. 3. Inability to void with a history of benign prostatic hyperplasia (BPH). 4. Purulent drainage from the penis.

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's Disease (AD). What signs should the nurse include? 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1,2

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1,2

The home health nurse is caring for a client who is identified as high risk for falls. What evaluation would indicate a therapeutic response to home fall prevention education? 1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. 3. Only uses assistive devices when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping.

1,2

Which nursing statements about a client reflect correct documentation in the hospital medical record? 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

1,2

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

1,2,3,4

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1,2,3,4,5

Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae

1,2,3,5

An unresponsive client is admitted to the emergency room with suspected alcohol poisoning. What intervention should the nurse initiate? 1. Insert a nasogastric tube 2. Pad side rails 3. Position supine with head of bed elevated 4. Obtain blood sample for glucose level 5. Start an IV using a large bore catheter

1,2,4,5

A client wishing to stop smoking receives a prescription for bupropion from the healthcare provider. What educational points should the nurse include regarding this medication? 1. This medication can cause a false positive drug screening test. 2. Alcohol intake should be limited to two drinks per day. 3. Nicotine gum may be prescribed in addition to bupropion. 4. An increased interest in sexual activity occurs while taking this medication. 5. Smoking can continue for 1 week after starting this medication.

1,3,5

During a yearly checkup, an adult client asks the Healthcare Provider to examine a mole which has recently become bothersome. The HCP is concerned about the appearance of the mole and refers the client to a specialist. The nurse is asked to assemble the documents to be sent with the client. The nurse knows what documents are important to send to the specialist? 1. The most recent history and physical findings. 2. History of childhood diseases and vaccinations. 3. List of all current medications and allergies. 4. X-ray results of last year's broken clavicle. 5. Insurance info with consent for release. 6. Current diagnoses and treatments.

1,3,5

Which client would be appropriate for the RN to assign to the LPN? 1. Client requiring enemas and antibiotics. 2. Newly admitted client with diagnosis of diabetic ketoacidosis (DKA). 3. Client returning from surgery post right upper lobectomy. 4. Client with frequent reports of nausea and vomiting following chemotherapy. 5. Client requiring frequent sterile dressing changes.

1,4,5

The charge nurse of a large medical-surgical unit is admitting several clients requiring specific infection control precautions. The nurse is aware that droplet precautions are necessary for which client diagnosis? 1. Mumps 2. Methicillin resistant Staphylococcus aureus (MRSA) 3. Shingles (Herpes Zoster) 4. Human immunodeficiency virus (HIV) 5. Pertussis

1,5

The nurse is caring for a client due for a dose of fluphenazine 10 mg. The drug is available as an elixir: 5 mg / 5 mL. How many mL will the nurse give to the client? ______mL. Round answer to the nearest whole number.

The nurse, preparing to begin Heparin therapy on a client admitted to the hospital, is calculating the hourly unit dose from the prescription received to ensure that it is within the safe and effective range. What hourly unit dose should the nurse obtain? Use numbers only. Exhibit

1200

A 154 pound (70 kg) client is admitted to the burn unit with second and third degree burns covering 50% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 ml/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer using whole numbers. Enter the answer for the question below. mL

1400mL

A client has recently been diagnosed with rheumatoid arthritis. The nurse anticipates which class of pharmacologic agents will likely be a part of the client's treatment regimen? 1. Mitotic inhibitors 2. Systemic glucocorticoids 3. Antifungals 4. Anticoagulants

A client newly diagnosed with insulin dependent diabetes mellitus is started on regular insulin. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

The nurse assesses a client post thyroidectomy for complications by performing which assessment? 1. Accucheck 2. Chovostek's 3. Ballottement 4. Ice water colonic

A nurse manager is monitoring staff nurse compliance with regulatory guidelines regarding administration of controlled substances. Which actions by the staff nurses indicate to the nurse manager compliance is being maintained? 1. Removes meperidine from computer controlled dispensing system and places in client medication drawer for later use. 2. Second nurse verifies and signs as a witness to morphine 2 mg wasted according to facility protocol. 3. Verification is made of the number of narcotics available against the inventory record prior to narcotic removal. 4. Second nurse provides verifying signature for removal of hydromorphone from the computer controlled dispensing system. 5. Narcotic discrepancy in the computer controlled dispensing system is reported to the primary healthcare provider.

2,3

What instructions should the nurse include when teaching a mother, whose newborn has hyperbilirubinemia, regarding phototherapy and its effects? 1. Breastfeeding should be discontinued until phototherapy is completed. 2. Feed newborn at least every 2-4 hours. 3. Make sure the newborn's eyes are closed when applying eye patches. 4. Keep the baby quiet and swaddled. 5. Report immediately if the urine becomes dark in color.

2,3

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome? 1. Assess for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Have client perform active range of motion (ROM) every 2 hours while awake.

2,3

A nurse is planning an educational session on fluticasone/salmeterol for a group of clients who have been prescribed this medication. What teaching points should the nurse include? 1. Swallow the capsule when having an acute asthma episode. 2. Rinse mouth after medication administration to decrease infection. 3. Take this medication every day, even on days when breathing fine. 4. Administer by HandiHaler DPI, twice daily. 5. Carry a rescue inhaler, such as albuterol, when leaving home.

2,3,4,5

A nurse is planning to teach a group who works at a local mall about proper use of automated external defibrillators (AED). Which points should the nurse emphasize? 1. The standard AED can be used on children over the age of 5. 2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

2,3,4,5

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2,3,4,5

Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Place client on Nothing By Mouth (NPO) status. 6. Administer Normal Saline (NS) at 125 mL/hour.

2,3,4,6

A nurse is caring for a client who has been prescribed metoprolol. What education should the nurse provide to the client? 1. Information on skin turgor. 2. Check for edema in lower extremities. 3. Take medication 30 minutes prior to a meal. 4. Do not use over the counter (OTC) nasal decongestants. 5. Notify primary healthcare provider if the pulse is < 60 beats per minute.

2,4,5

A nurse is educating several unlicensed assistive personnel (UAP) about a dietary prescription for clear liquids. Which selections by the UAP indicate to the nurse an understanding of a clear liquid diet? 1. Vanilla custard 2. Lemon jello 3. Tomato juice 4. Sprite 5. Banana popsicle

2,4,5

The nurse is discussing appropriate toys for toddlers with a group of parents. What toys should the nurse include? 1. Board games 2. Finger paint 3. Swing set 4. Water squirting toys 5. Play telephone 6. Wooden spoons

2,4,5,6

At orientation for a new nurse, the charge nurse on the neuro unit reviews tests requiring informed consent which may be ordered for clients. The charge nurse knows the review was successful if the new nurse indicates a signed consent is required for what test(s)? 1. Computerized tomography 2. Cerebral spinal fluid analysis 3. Magnetic resonance imaging 4. Electroencephalogram 5. Cerebral angiogram

2,5

The nurse is preparing to hang an IV bottle of fat emulsions 20% on a client. How many mL should be delivered in 12 hours? Answer in numbers only. Exhibit

204

The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 10 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.

The nurse is preparing to give 250 mL D5W IV over 2.5 hours. How many gtts/min will the nurse need to set the IV rate at? Exhibit

The primary healthcare provider has prescribed 1000 mL of D5W to infuse over a 12 hour period. The drop factor is 20 gtt/mL. How many gtt/min should the nurse administer? Round answer to the nearest whole number.

27.8

A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

The nurse is teaching a client diagnosed with salmonellosis about how to decrease the transmission to others. Which statement by the nurse would require follow up? 1. "I will wash my hands after feeding pets." 2. "I will use a meat thermometer to cook food to safe temperature." 3. "I will clean my hands with water before handling food." 4. "I will use disposable dishes until infection free."

The previous shift nurse reported to the oncoming nurse a suspicion that a client's central line has developed a fibrin sheath. Which prescription does the nurse anticipate the healthcare provider will prescribe? 1. Heparin 2. Enoxaparin 3. Alteplase 4. acetylsalicylic acid

Which comment made by a client scheduled for a lumbar laminectomy and discectomy indicates to the nurse that the client needs further teaching? 1. After the incision is healed, I can go for daily walks. 2. By the time I am discharged, my back and leg pain will be better. 3. I can turn by myself after surgery, but I will need help to get out of bed. 4. The staff will frequently check my feet and legs for feeling and movement.

What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit? 1. Asymmetrical chest expansion 2. Night sweats 3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus

3,4,5,6

A new nurse on a telemetry unit has been assigned a client admitted for treatment of congestive heart failure (CHF). When completing a cardiac output assessment, the nurse would evaluate what body function? 1. Skin turgor 2. Bowel sounds 3. Urinary output 4. Pupillary reaction 5. Peripheral edema 6. Level of consciousness

3,5,6

A newly admitted client informs the unit nurse the current identification band has the correct name but an incorrect birthdate. The best action by the nurse at this time is what? 1. Report the error to the HCP immediately. 2. Call family to verify the correct birthdate. 3. Tell client not to worry since name is correct. 4. Call Admissions office and request new band.

What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. Inform the client of the need to avoid irritants such as carbonated beverages. 2. Ask client if they are eating small, frequent meals. 3. Monitor for GI upset 30 minutes after meals. 4. Remind the client to avoid tight fitting clothes.

A client diagnosed with thrombophlebitis is receiving an IV heparin infusion via a single port saline lock. The primary healthcare provider has just ordered an intravenous antibiotic. What action(s) by the nurse take priority at the time? 1. Call pharmacist to determine compatibility. 2. Contact HCP to verify the need for IV antibiotic. 3. Piggyback antibiotic into heparin tubing to infuse. 4. Start another IV site to infuse the antibiotics. 5. Tell client to report any untoward side effects.

4,5

The nurse is caring for a client on the medical unit. The primary healthcare provider prescribed Lactulose 30 gram orally once a day. Available is Lactulose labeled 10 g per 15 mL. How many mL will the nurse administer? Round answer to the nearest whole number.

The primary healthcare provider's prescription for a client instructs the nurse to give digoxin 0.125 mg intravenously as a one-time dose. The available medication is in a concentration of 0.5 mg/2 mL. How many milliliters should the nurse give? Round answer using one decimal point.

5 mL

A healthy newborn has just been delivered and placed in the care of the nursery nurse. What nursing actions should the nursery nurse initiate? Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

This is the correct order

A 15 year old is being admitted with pelvic inflammatory disease. Which client could the charge nurse assign the new admit to room with? 1. 18 year old who sustained a compound fracture. 2. 15 year old diagnosed with anorexia nervosa. 3. 13 year old admitted with pneumonia. 4. 14 year old who is taking steroids for chronic asthma.

A 35 year old client asks a clinic nurse how to find out if the client is overweight or obese. The client weighs 135 pounds and is 5 feet 2 inches tall. What should the nurse educate the client about? 1. Calculating body mass index 2. Measuring abdominal circumference 3. Determining lean body mass 4. Finding the nearest hydrostatic testing location

A 40 year old client reports a diminished ability to visually focus on close objects and has also noticed a need for a well lit environment to enhance vision. To what would the nurse attribute these changes? 1. Normal changes associated with aging. 2. A cataract is forming. 3. Symptoms of a brain tumor. 4. Precipitated by diabetic retinopathy.

A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.

A client arrives at the Emergency Department after receiving 3rd degree burns to the upper chest, neck, and face area. What would be the priority nursing intervention? 1. Prepare for endotracheal intubation. 2. Monitor hourly urinary output. 3. Treatment of the open burn wounds. 4. Assessment and management of pain.

A client with a supra-pubic catheter is admitted for surgery and requires a catheter change before that procedure. The nurse is aware the most important action prior to changing this catheter is what? 1. Check size of existing catheter and balloon. 2. Ask client when the catheter was last changed. 3. Clamp and empty the present catheter bag. 4. Gather clean gloves and basin of hot soapy water.

After receiving report from the previous shift nurse, Which client should the nurse assess first? 1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. 2. Client diagnosed with dementia who needs assistance with ambulating. 3. Client with a halo device requesting to be transferred to the bedside chair. 4. Client diagnosed with a traumatic brain injury who cannot recall portions of the accident.

The nurse is assessing a client admitted with acute gastritis. Which client information is most significant? 1. Takes ibuprofen for arthritis pain. 2. Had an upper respiratory infection two weeks ago. 3. Has a stressful job. 4. Enjoys spicy food.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which finding would indicate the need to increase the irrigation rate? 1. Clots in urine 2. Unable to palpate bladder 3. Slightly pink tinged urine 4. No report of bladder spasms

The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know that he loves me. Sometimes I can be quite irritating." Which response is most appropriate by the nurse? 1. "You are not responsible for the abuse." 2. "Sometimes we can irritate our spouses." 3. "The worst is over now." 4. "You should think about leaving him."

The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern? 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypocalcemia

The nurse is caring for a client who is preparing to undergo a total hysterectomy for stage 4 cervical cancer. The client is crying and states, "I want to have more children, and I am unsure if I should have the procedure." What is the nurse's best action? 1. Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider. 2. Discuss the fun things that she will be able to do after her surgery, and encourage her to make a list of positive things. 3. Explain to the client that her ovaries can be frozen for egg harvesting at a later time, and she can find a surrogate. 4. Advise the client to put off having the surgery until she is certain, and notify the surgeon of the decision.

The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? 1. Promotes the return of venous blood to the heart and assists in preventing blood clots. 2. Stabilizes any clots to prevent embolization. 3. To increase the blood pressure in the venous system in the legs to promote perfusion. 4. Promotes lymphatic drainage to prevent swelling and arterial congestion.

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.

The nurse is monitoring a client in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? 1. pH 7.32 2. PaCO2 47 3. HCO3 25 4. PaO2 78

The nurse, performing an initial physical assessment on a client determines that the client has difficulty hearing questions. The nurse also notices an empty eyeglass case. Based on this information, which action should first be taken by the nurse? 1. Determine which ear the client hears best from or if there is a hearing deficit is bilateral. Then ask about the empty eyeglass case. 2. Ask client about use of any assistive devices and document the client's response. 3. Look through client's belongings to determine if there is a pair of glasses and a hearing aid. 4. Notify the primary healthcare provider of client's difficulty hearing and the empty eyeglass case.

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm.

What is the most important action for the nurse to take in order to decrease an adverse drug reaction/interaction in an elderly client who takes multiple medications? 1. Implementing a thorough client assessment. 2. Instructing the client about adverse drugs reactions. 3. Explaining to the client that hospital admissions of older adults are often due to a drug reaction. 4. Teaching the client that adverse reactions are directly proportional to the number of medications taken.

Which assignment would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Totaling I & O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? 1. Provide for scheduled toileting intervals. 2. Apply a restraining vest on the client at night. 3. Cover the IV site with a gauze dressing. 4. Remind client to ring call bell for the nurse.

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.

1,2,3

A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a VMA (Vanillylmandelic acid) urine test to be complete at home. What statement made by the client indicates the need for further teaching? 1. "I need to keep the urine in the fridge during the 24 hours." 2. "I will have to stay well-hydrated to get enough urine to test." 3. "It does not matter what I eat or drink during this process." 4. "I need to throw away my first voiding when I start this test." 5. "I should void at the end of the 24 hours and keep that urine."

1,2,3

A nurse plans to educate a group of new parents about how to prevent burn injuries in children. What should the nurse include? 1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets. 4. Warm baby bottle in microwave for 30 seconds. 5. Set the hot water heater thermostat to 140°F (60°C).

1,2,3

The nurse is teaching the family of a homebound client about ways to increase the client's safety while bathing independently. Which strategies should the nurse include? 1. Install grab bars in the tub or shower. 2. Install hand bars on sides of tub. 3. Use tub/shower seat for bathing. 4. Provide a long handled bath scrubbie for bathing. 5. Schedule bathing routines three times per week.

1,2,3,4

What action should the nurse take after mistakenly administering the wrong medication? 1. Notify the nursing supervisor. 2. Inform the primary healthcare provider. 3. Complete an incident (variance) report. 4. Document client assessment and response to medication. 5. Document medication error and incident (variance) report in nurse's notes.

1,2,3,4

What developmental milestone does the nurse expect to see in an 18 month old toddler? 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.

1,2,3,4

The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include? 1. Keep TVs, iPads, and other screens out of kids' bedrooms. 2. Turn off all screens during meals. 3. Allow screen time only after chores and homework are complete. 4. Have a screen free day once a week. 5. Limit screen time to 2 hours daily. 6. Use screen time as a reward for good behavior.

1,2,3,4,5

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1,2,3,4,6

The nurse is caring for a client diagnosed with myasthemia gravis. What assessment finding would the nurse expect to see in this client? 1. Difficulty chewing 2. Drooping eyelids 3. Facial paralysis 4. Hoarseness 5. Limb rigidity 6. Trouble talking

1,2,3,4,6

The nurse is discussing appropriate toys for preschoolers with a group of parents. What toys should the nurse include? 1. Six piece jigsaw puzzles 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 5. Jump rope 6. Sewing cards

1,2,3,4,6

What risk factors should the nurse include when teaching a group of clients about osteoarthritis? 1. Sports injury to joint 2. Genetic predisposition 3. Obesity 4. Male sex 5. Repetitive joint stress

1,2,3,5

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1,2,4,5

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

1,2,4,5,6

The nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the unlicensed assistive personnel (UAP)? 1. Assist the client with toileting. 2. Inform family that the client needs a Computed Tomography (CT) scan. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. 5. Apply restraint belt for client safety.

1,3,4

The crisis line nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What is the nurse's most appropriate response? 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."

1,3,4,5

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1,3,4,5

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1,3,5

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.

1,3,5

An oncology client with a Hickman catheter is being discharged to receive chemotherapy via cassette pump at home. The nurse is aware that discharge instructions should include what information? 1. Always use two pairs of gloves when preparing chemotherapy medications. 2. Discarded chemotherapy cassettes and tubings can be placed in regular trash. 3. Used needles or syringes must be placed into plastic chemotherapy receptacle. 4. Linens soiled with chemotherapy drugs can be washed with regular laundry. 5. Waste is placed into chemotherapy bags and picked up by medical supplier. 6. Regular home cleaning products are appropriate for spilled chemotherapy medications.

1,3,5

A medical secretary is transcribing hand written medical orders for several clients. When the charge nurse reviews the orders, several seem to have transcription errors. What orders should the nurse verify immediately with the primary healthcare provider? 1. "Adm. Diagnosis: Anterior MI cardiac enzymes x 3 & 12-lead ECT." 2. "S/P cataract removal to OD Continue eye gtts twice daily to OU" 3. "H & P: Client indicates hx of cirrhosis with HDV, HTN and IDDM." 4. "Dx: renal insufficiency. Fluid restriction 1000mL/24 hr with I & D q shift." 5. "Reports hx of COPD x 20 years, with occasional wet cough and SBO."

1,4,5

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide to the client? 1. "The medicine might make your blood much too thin." 2. "It helps us monitor and adjust the dose to work better." 3. "It is required for anyone getting heparin intravenously." 4. "The test results tell us whether the treatment is working."

A client in the third trimester of pregnancy arrives at the emergency room reporting general illness. The client is noted to have a blood glucose level of 390 mg/dL and is diagnosed with gestational diabetes. The primary healthcare provider prescribes 30 units of NPH insulin subcutaneously stat. What is the nurse's priority action? 1. Administer the dose of insulin immediately. 2. Question the type of insulin prescribed. 3. Insert an IV for an insulin infusion. 4. Question the dose of the insulin.

A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure? 1. Sterile vaginal exam 2. Ultrasound exam 3. Amniocentesis 4. Contraction stress test

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Exhibit 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output

A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.

A client was started on captopril three weeks ago and has returned to the health clinic for a checkup. What symptom noted during assessment would the nurse consider of priority concern? 1. Rash on both arms 2. Fever of 102.0º F 3. Dry hacking cough 4. Tachycardia

A client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit from two units of blood. What should the nurse do? 1. Prepare the client for the administration of blood. 2. Explain to the primary healthcare provider that the client's faith prohibits blood transfusions. 3. Explain to the client that the blood transfusions are needed for return to health. 4. Try to convince the client to accept the transfusions.

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

The nurse is caring for a client taking enoxaparin. Which group of symptoms should be reported to the primary healthcare provider? 1. AST of 12 U/L and ALT 20 U/L 2. Hematocrit of 46% decreased to 35% and blood pressure decreases from 122/78 to 108/54 3. Ecchymosis around the abdominal subcutaneous injection site and platelet count of 200,000. 4. Hemoglobin of 14.5 g/dL (2.3 mmol/L) increased to 16 g/dL (2.5 mmol/L) and increased erythemia of oral mucus membranes.

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by turning on the TV. 3. Contact the primary healthcare provider for a pain medication prescription. 4. Request that the parents leave the room.

The nurse on an inpatient psychiatric unit has been assigned to care for a group of clients. Which client should receive priority during morning round assessment? 1. 40 year old woman who is being discharged today. 2. 80 year old man with suicidal thinking. 3. 45 year old man who has suicidal thinking. 4. 50 year old woman with history of acute panic attacks.

A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? 1. Cooking a meal. 2. Shampooing hair. 3. Doing the laundry. 4. Vacuuming carpets. 5. Changing bed linens.

2,3,5

The nurse is preparing a seminar for a group of clients diagnosed with irritable bowel syndrome. Which point should the nurse include? 1. Teach about a low fiber diet. 2. Schedule meals at regular times. 3. Fluid should be taken with meals. 4. Become active in yoga classes. 5. Keep a food diary for 2 weeks.

2,4,5

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

2,5

A client has been admitted to the emergency department after repeated food binging and purging by vomiting and laxative abuse. The client reports leg pains and weakness. ECG reveals a depressed ST segment and flattened T wave. Based on this data, what does the nurse anticipate that this client will need to receive first? 1. Oral fluids 2. Kayexalate enemas 3. Intravenous potassium (KCL) 4. An antidiarrheal medication

A community health nurse is reconciling medications of a client who was discharged from the hospital with a diagnosis of congestive heart failure, hypertension, and arthritis. After reviewing the client's medications, what action is most important for the nurse to take? Exhibit 1. Educate the client on the newly prescribed medications. 2. Inform the client to take the captopril at night. 3. Notify the primary healthcare provider that the client is receiving adalimumab. 4. Tell the client to stop taking saw palmetto.

A factory employee is brought to the emergency room on first shift with a severe hand laceration occurring at work. The employee is quite upset, indicating previous competency on the machine. When reviewing medications, the nurse notes the client has recently started alprazolam at bedtime. What vital information about this medication should the nurse provide to the client? 1. Consider getting new glasses. 2. Stand up slowly when sitting. 3. Do not operate dangerous machines. 4. Instructions for taking medication appropriately.

A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

The nurse is caring for a client diagnosed with deep vein thrombosis, who has been treated with intravenous heparin for one week. The primary healthcare provider plans to change the medication from heparin IV to warfarin sodium by mouth. The nurse understands which approach would be appropriate? 1. Begin the warfarin sodium and stop the heparin simultaneously. 2. Stop the heparin 24 hours, then begin the warfarin sodium. 3. Begin the warfarin sodium before stopping the heparin. 4. Stop the heparin, wait for the coagulation studies to reach the control value, and begin the warfarin sodium.

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

The parents of a toddler ask the nurse how to stop their child's temper tantrums when they occur. What is the best advice the nurse should provide? 1. Spank the child gently when the tantrum occurs. 2. Promise the child a new toy if the child stops the tantrum. 3. Ignore the tantrum if the child is safe. 4. Restrain the child during a tantrum.

The primary healthcare provider prescribed 0.125 mg of digoxin daily for a client. On hand, the nurse has digoxin 0.25 mg/mL. How many mLs of digoxin should the nurse administer? 1. 5 mL 2. 3 mL 3. 0.5 mL 4. 0.3 mL

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

What task would be most appropriate to assign to the UAP when caring for a client with ulcerative colitis? 1. Sharing successful anxiety reduction measures. 2. Encouraging the client to express concerns about an ileostomy. 3. Reminding the client to avoid cold foods and smoking. 4. Explaining the rationale for needing a low residue diet.

What would be the nurse's priority for a child who has arrived at the emergency department after sustaining a severe burn? 1. Start intravenous fluids. 2. Provide pain relief. 3. Establish airway. 4. Place an indwelling catheter.

What would the nurse include when teaching a client newly prescribed timolol maleate eyedrops for glaucoma? 1. The medication works by causing the pupils to constrict 2. The medication will dilate the canals of Schlemm 3. This medication decreases the production of aqueous humor 4. The medication improves ciliary muscle contraction

When making assignments for an LPN on the Labor and Delivery unit, the charge nurse is aware the most appropriate clients should meet what criteria? 1. Clients requiring close monitoring. 2. Post-vaginal delivery clients only. 3. Clients with a predictable outcome. 4. Non-routine clients in early labor.

Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans

Which side effect of vincristine should the nurse immediately report to the primary healthcare provider? 1. Nausea 2. Fatigue 3. Paresthesia 4. Anorexia

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

3,4,5

Which client diagnosis would a prescription for an intravenous infusion of 1000 mL normal saline with 20 mEq (20 mmol) potassium chloride be appropriate? 1. Major burn injury 2. Kidney disease 3. Abdominal cramping with diarrhea 4. Diabetic Ketoacidosis (DKA) 5. Hypokalemia

3,4,5

What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches

3,5,6

A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? 1. "Would you like me to ask the doctor to increase your dose?" 2. "You might need to be changed to a different medication." 3. "Tell me what type of situations make you feel depressed." 4. "Some medications take a little longer to improve moods."

A client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond? 1. "I can see that you miss your wife very much." 2. "Tell me about your wife." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?"

A client who is occasionally confused states that the medication is the wrong color when the nurse hands it to the client. What action should the nurse take? 1. Encourage the client to take the medication. 2. Tell the client that the medication is correct. 3. Explain that generic medications may be different colors. 4. Double check the medication before administering.

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? 1. No follow up care will be needed after the monitor is removed. 2. It is okay to shower or bath while wearing this equipment. 3. I have to take it easy and not exercise for the next two days. 4. It's important to write down all my activities during this time.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

A first generation Hispanic-American has been admitted to the psychiatric unit after being diagnosed with severe panic disorder. When developing the plan of care for this client, to which cultural background information should the nurse give priority? 1. Discuss treatment in terms of future plans for this client. 2. Do not use touch when communicating with this client. 3. Include the Protestant minister in the spiritual care of the client. 4. Allow family members to visit regularly.

A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 1. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

A nurse delegates an unlicensed assistive personnel (UAP) to transfer a client from the bed to a wheelchair with a mechanical lift. The UAP states "It has been a long time since I used the lift." To ensure that the UAP can properly operate the mechanical lift, which intervention would the nurse implement? 1. Assign the client to another UAP. 2. Verbally discuss the procedure for the lift. 3. Instruct the UAP to physically transfer the client. 4. Ask the UAP to demonstrate how to use the lift.

A nurse is caring for a client who has been prescribed clonazepam for 6 months. What education should the nurse provide to the client? 1. "Your glucose level should be monitored while prescribed clonazepam." 2. "You may experience dry skin periodically while prescribed clonazepam." 3. "Schedule appointments to have clonazepam administered intravenously." 4. "A long-term prescription of clonazepam should be discontinued gradually."

An elderly client with a recent diagnosis of atrial fibrillation (AF) caused by valvular heart disease, tells the nurse, "My daughter has AF and she only has to take one dabigatran pill a day. I have to take warfarin daily and have my blood checked every month. Why do I have to do all of this?" What education would the nurse provide to the client? 1. Your daughter's atrial fibrillation must not be caused by a heart valve problem so she can take a medication that does not require routine clotting studies. 2. Each primary healthcare provider may treat this dysrhythmia differently based on what the provider is used to prescribing. 3. When your daughter gets older, her primary healthcare provider will switch her to warfarin for the treatment of atrial fibrillation. 4. Your atrial fibrillation is caused by a heart valve problem which is treated best by warfarin, but clotting studies have to be done routinely.

An injured client brought to the emergency room by ambulance insists on leaving before being seen by the primary healthcare provider. What is the nurse's priority action? 1. Explain potential risks of leaving without proper care. 2. Insist the client sign "Against Medical Advice" form. 3. Calmly convince client to wait for needed treatment. 4. Notify primary healthcare provider immediately.

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? 1. Clean and restock exam rooms after client discharge. 2. Follow another UAP who has worked there previously. 3. Sit at the reception desk and answer incoming calls. 4. Escort clients from the ED to other areas for tests.

Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only? 1. The client with chicken pox. 2. The client with rubeola. 3. The client with impetigo. 4. The client with pancreatitis.

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

The parents of a nine month old ask the nurse for toy recommendations. What recommendation should the nurse to make? 1. Mobile 2. Tricycle 3. Marbles 4. Pull toy

A client comes to an obstetric clinic for a routine prenatal checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart sounds can be assessed. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Below the umbilicus, on the mother's left side. 2. Below the umbilicus, on the mother's right side. 3. Above the umbilicus, on the mother's right side. 4. Above the umbilicus, on the mother's left side.

A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR42, Cheyne-Stokes respirations. Based on this assessment the nurse anticipates the client to be in which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

A client is admitted to the hospital with acute exacerbation of COPD following an upper respiratory infection. His daughter found him at home, confused and in respiratory distress, a day after he developed a cold. He was placed on 4 L/min of oxygen via nasal cannula, but oxygen saturation remains at 89%. Based on this assessment, the nurse suspects that the client has developed which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agent? 1. Proton pump inhibitor 2. Mitotic inhibitor 3. Serotonin antagonist 4. Acetylsalicyclic acid

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future? 1. During the end-of-shift report, assign specific staff to check on each client. 2. Place newly admitted clients close to the nursing station. 3. Monitor level of suicide precaution needed on each client daily. 4. Ask clients to check on each other throughout the shift.

A client who is suicidal confides to the night nurse, "I will try again when I get out of this place." What is the nurse's best response? 1. "What do you plan to do?" 2. "You will try what again?" 3. "Why would you want to do that? You have everything to live for." 4. "Are you trying to get back at your family for sending you here?"

In which client should the nurse question the prescribed medication levofloxacin? 1. History of myasthenia gravis. 2. Has a prescription for verapamil. 3. Thrombocytopenic 4. Admitted with renal arterial stenosis.

The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.

Which food selections would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream

Which information should the nurse plan to teach family members of a client diagnosed with hepatitis B? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes separately from the rest of the family's. 3. Wear a surgical mask when in close proximity to the client. 4. Use a separate bathroom from the client.

Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the waste basket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian

Which statement by the client with children ages 5 months to 8 years old requires follow up by the clinic nurse? 1. "I give all my children a spoonful of honey at night when they have a cough." 2. "I serve my 8 year old a glass of orange juice with breakfast before school." 3. "I have children use Lavender scented soap to wash their hands before they eat. 4. "I play music for my children when it is time for them to take a nap."

Which statement by the nurse would be the correct response to a client who is postmenopausal with a uterus when the client asks about temporary hormonal therapy for hot flashes? 1. "Hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed." 2. "Unopposed estrogen hormonal therapy would be most appropriate." 3. "Hormonal therapy is an outdated treatment and can no longer be prescribed so you should try an alternative such as ginseng." 4. "Hormonal therapy is not an option for women with a uterus so you may need to consider a hysterectomy."

1,2,3

The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.

1,2,3

The client with a new diagnosis of hypertension has been instructed to maintain a low sodium diet. Which foods does the nurse plan to teach the client to include on a low sodium diet? 1. Lemonade 2. Broccoli 3. Apple 4. Smoked sausage 5. Boiled shrimp 6. Tomato soup

1,2,3

The nurse educates a client that the prescribed medication indomethacin is used to manage which symptoms? 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria

1,2,3

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1,2,3

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1,2,3,4

A client has been instructed not to take non-steroidal anti-inflammatory drugs (NSAIDs) post lumbar laminectomy with spinal fusion. The nurse knows that education was successul when the client identifies which medications should be avoided? 1. Celecoxib 2. Ibuprofen 3. Naproxen 4. Acetaminophen 5. Indomethacin

1,2,3,5

The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell the victim about the process? 1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 4. You will spend approximately 15 minutes in the shower. 5. You will apply soap from head to toe and then rinse for a few minutes.

1,2,3,5

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan? 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1,2,3,5

Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis? 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen

1,2,3,5

A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse implement for the client's night sweats and fever. 1. Keep water by the bedside 2. Place a plastic cover over the pillow 3. Administer an antipyretic every 4 hours 4. Keep a change of linen in the room 5. Position the client in a semi-fowlers position

1,2,4

A nurse is in the mall when a shopper who suddenly becomes non-responsive. Obtaining an available AED, the nurse would initiate what emergency interventions? 1. Clear everyone before shock. 2. Turn on the machine. 3. Initiate shock immediately. 4. Place pads on client's chest. 5. Await arrival of paramedics. 6. Shave client's chest.

1,2,4

The home care nurse is caring for an elderly client status post total hip replacement and a history of cirrhosis. Which statements by the client's spouse indicates that teaching regarding pain management has been successful? 1. "If the pain increases, I must let the nurse know immediately." 2. "I should have my spouse try the breathing exercises to help control pain." 3. "This narcotic causes very deep sleep, which is what my spouse needs." 4. "If constipation is a problem, increased fluids will help." 5. "My spouse can have one glass of wine to help promote pain relief."

1,2,4

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1,2,4

The employee health nurse is designing a health promotion plan for a group of workers who have neck and back strain symptoms and repetitive movement pain from long periods of computer work. Which interventions should be included in the plan to reduce these symptoms? 1. Suggest that the workers place the keyboard and mouse close to the body. 2. Adjust computer screen to below eye level. 3. Drop and roll shoulders periodically. 4. Type with forearms parallel to the floor. 5. Keep elbows at the side when typing.

1,3,4,5

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1,3,4,5

The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? 1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 2. Gestational age 38 weeks. 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.

1,3,4,5

Which tasks are most appropriate for the hospice nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs

1,3,5,6

What actions would be appropriate for a nurse who is administering ear drops to a six year old child? 1. Position supine with affected ear up. 2. Administer ear drops immediately upon removing from the refrigerator. 3. Open ear canal by drawing back on the pinna and slightly downward. 4. Allow prescribed number of drops to fall along inside of ear and flow into ear by gravity. 5. Have client remain supine for several minutes.

1,4,5

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections (STI)? 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs

1,4,5

Which medications, if prescribed to a client, should indicate to a nurse that retention of CO2 is a possibility? 1. Narcotics 2. Diuretics 3. Glucocorticoid steroids 4. Antiemetics 5. Hypnotics

1,4,5

A client arrives at the emergency room with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and life style with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? 1. A daily glass of white wine. 2. Bacon and eggs on weekends. 3. Smoking two cigars every day. 4. One half liter of soda daily. 5. Baked cod twice a week. 6. A BMI of 31.5 kg/m2.

1,4,5,6

The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective? 1. Financial abuse of an elder 2. Negligence of a colleague 3. Spousal abuse denied by the victim 4. Gunshot victim 5. Client diagnosed with Gonorrhea 6. Client diagnosed with West Nile virus

1,4,5,6

A 16 year old female student is escorted to the school nurse after fainting in gym class. The student tells the nurse, "I just got weak from running." Upon examination, the nurse notes poor skin turgor, dry mucous membranes, and erosion of tooth enamel from her front teeth. Height is 5'4" (162.56 cm) and weight is 110 lbs (50 kg). The student reports muscle pain in the legs. Based on this data, what should the nurse suspect? 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Obesity 4. Physical violence

A client diagnosed with Alzheimer's disease becomes agitated and combative when the nurse approaches to perform a shift assessment. What would be the most appropriate first action for the nurse to take? 1. Obtain assistance to restrain the client. 2. Talk quietly to the client. 3. Administer haloperidol. 4. Leave until the family can calm the client down.

A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."

A client is being scheduled for a cat scan (CT) of the abdomen with contrast. When considering client safety, what should be the priority action for the nurse to implement? 1. Verify that informed consent has been provided. 2. Confirm with client the accuracy of allergies listed. 3. Force fluids following procedure. 4. Monitor output following procedure.

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor.

A nurse is teaching a group of expectant parents about epidural anesthesia. What information should the nurse include? 1. Contraindications for an epidural include a previous cesarean section. 2. Post procedure position should be side lying. 3. Headache is a post procedure side effect. 4. The major complication is hypotension. 5. Usually administered at 3-4 cm dilation.

2,4,5

An elderly client who lives alone is being discharged home following a total hip replacement. The home care nurse is completing a safety assessment of the home environment prior to the client's arrival. Which conditions would require modifications to ensure client safety? 1. Wall-to-wall carpeting 2. Entrance throw rugs 3. Downstairs bathroom 4. Rail-free porch stairs 5. Step stool in kitchen

2,4,5

The nurse is preparing to educate a group of clients on how to decrease the risk of developing recurrent renal calculi. What topics should the nurse include? 1. High-purine foods to consume 2. Discuss diuretic use to prevent urinary stasis 3. Straining urine with each void 4. Maintaining a daily water intake of at least 2 liters 5. Foods low in calcium

2,4,5

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

A client comes into the women's clinic with amenorrhea, breast tenderness, and urinary frequency. Which term should the nurse use to describe these signs/symptoms of pregnancy? 1. Probable 2. Positive 3. Presumptive 4. Early

A client prescribed oral iron medication is reporting nausea after administration. What should the nurse teach the client to decrease this symptom? 1. Take the iron with a class of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.

A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD)

A high school nurse is assessing multiple students reporting general flu-like symptoms. Which additional symptoms reported by a student would prompt the nurse to immediately call an ambulance? 1. Blurred vision and Trousseau's sign. 2. Vomiting and a Murphy's sign. 3. Sensitivity to light and Kernig's sign. 4. Fever and a Chvostek's sign.

The nurse is providing care to a client who had an endoscopic retrograde cholangiopancreatogram (ERCP) two hours ago. Which finding would indicate a possible complication? 1. Occasional cough 2. Sore throat reported 3. Abdominal pain rated 8/10 4. Drowsy

While suctioning a client's endotracheal (ET) tube, the nurse notes that the client's heart rate has gone from 78 to 44. The nurse stops suctioning the ET tube. What is the nurse's best action? 1. Deflate the ET tube cuff. 2. Have the client cough several times in a row. 3. Oxygenate the client with 100% oxygen. 4. Notify the primary healthcare provider.

A homecare nurse is attempting to visit clients isolated during the pandemic. Upon arriving at one small rural home, the nurse discoveries the client is almost out of food, has no wood for heating and has a broken water faucet. The client is alert, oriented and refuses to leave the home. There is no family to help the client. How could the nurse best assist the client to remain home at this time? 1. Call local ambulance crew to transport client to the hospital. 2. Ask the healthcare provider to order emergency placement. 3. Request immediate evaluation by senior protective services. 4. Run to the local store to obtain food and water for the client. 5. Develop a plan of care with client, based on present needs.

3,5

The nurse manager is developing a new yearly evaluation form for the staff. What statement(s) by the nurse manager would most likely improve staff outcomes? 1. "How often do you need help to finish assignments?" 2. "Are there any new skills you feel capable to learn?" 3. "Describe how you organize your daily assignments." 4. "Which tasks are most difficult for you to complete?" 5. "Explain any new goals you would like to achieve."

3,5

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 15, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

A RN and a LPN are caring for a client who is post-op total right hip replacement. Which action by the LPN would necessitate intervention by the RN? 1. Reinforcing teaching about the use of the overhead trapeze bar. 2. Reminding client of the need for using the incentive spirometer. 3. Reinforcing the hip dressing as needed due to breakthrough bleeding. 4. Providing socks for the client to put on to help warm the feet.

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity

The nurse enters the med room to prepare the AM medication pass. A new nurse is drawing up morning insulin using a tuberculin syringe instead of an insulin syringe. What is the nurse's priority action? 1. Report the new nurse to the charge nurse. 2. Offer to pass the medications for the new nurse. 3. Prepare an incident report describing the issue. 4. Offer to help the new nurse re-draw up the insulin.

The nurse has been working with a client who has a diagnosis of schizophrenia. The client has had three inpatient admissions in the past, but none in the past 6 months. Which statement by the client indicates adequate understanding of the medication treatment regimen? 1. I am feeling better so I hope that I don't have to take the medication for long. 2. I can stop the medication after I have been out of the hospital for a year. 3. The medicine is good for me now; however, I don't want to take it forever. 4. The medication keeps me out of the hospital, and I don't want to hear voices again.

The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat.

The nurse is caring for a client diagnosed with schizophrenia who is admitted to the hospital for possible bowel obstruction. The client has a nasogastric tube (NG) and reports pain 8/10. What is the priority nursing action? 1. Decrease the stimuli and observe frequently. 2. Administer the prn sedative. 3. Call the primary healthcare provider immediately. 4. Administer the prn pain medication.

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

Which statement by a client would indicate to the nurse that education about gastroesophageal reflux disease (GERD) has been successful? 1. It would be better for me to eat 3 small meals a day. 2. I need to avoid eating foods high in purine. 3. When going to sleep, I should lie on my side. 4. My last daily meal should not be within 2 hours of bedtime.

Which statement made by a client prescribed naproxen for rheumatoid arthritis would require further investigation by the nurse? 1. "I signed up for swimming classes at the local recreation center." 2. "I take acetaminophen when I have a headache." 3. "I have lost 2 pounds in the past 2 weeks." 4. "I am taking an antacid to help with indigestion."

The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? 1. Position client on the left side. 2. Apply warm blankets to legs. 3. Administer I.M. pain medication. 4. Alert the operating room staff. 5. Notify the primary healthcare provider. 6. Palpate mass to determine size.

4,5

The nurse asks if the client has an advance directive. The client responds by saying, "What is an advance directive?" What is the nurse's best response to the client's question? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. Specifies your wishes regarding healthcare and treatment options should you become incapacitated. 5. The person signing the advanced directive must be competent.

4,5

The nurse is caring for a client who sustained a head injury with possible seizure activity. The primary healthcare provider prescribes an EEG. What client teaching should the nurse provide to the client prior to this test? 1. Instruct client to be NPO after midnight. 2. Tell client not to wash their hair the night before the test. 3. Assure client that they may take sleeping pill the night prior to the EEG. 4. Instruct client not to drink caffeinated beverages the morning of the test. 5. Take routine medications the morning of the EEG with a sip of water.

4,5

In what order should the nurse assess assigned clients following shift report? Place in priority order. Client diagnosed with Addison's disease who is lethargic and has a BP of 86/48, P 120, and R 24. Client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. Client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. Client two days post thyroidectomy who has a negative Trousseau's sign.

This is the correct order

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

What should the nurse include in the teaching plan for a client receiving external beam radiation? 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.

1,3

Which signs/symptoms should the nurse monitor for in a client admitted with a diagnosis of pheochromocytoma? 1. Headache 2. Hypotension 3. Hyperglycemia 4. Bradycardia 5. Polycythemia 6. Leukopenia

1,3

An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment? 1. Monitor for peripheral edema. 2. Assess breath sounds. 3. Keep bedrails up at all times. 4. Monitor hemoglobin every 6 hours.

The nurse is assessing a client with advanced cirrhosis and notes an abdominal girth increase of 5 inches (12.7 cm) since yesterday. What is the best position for the nurse to place this client? 1. Supine 2. Semi Fowler 3. Trendelenburg 4. Lateral, left side

Which nursing intervention represents secondary prevention level? 1. Teaching the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

The nurse is teaching a newly diagnosed diabetic client about self-injection of insulin. Which statement made by the client indicates to the nurse that teaching has been effective? 1. "The abdominal site is best because it is closest to the pancreas." 2. "I can reach my thigh the best, so I will use different areas of the same thigh." 3. "By rotating the sites within one area, my chances of having tissue changes are less." 4. "If I change injection sites from the thigh to the arm, the rate of absorption will be different." 5. "I should inject at least 1-2 inches away from the last injection site."

2,3,4,5

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2,3,4,5

What interventions should the nurse include when planning care for a client post heart transplant? 1. Place on airborne precautions. 2. Instruct visitors to wash hands prior to entering the room. 3. Maintain strict aseptic technique. 4. Initiate pulmonary hygiene measures. 5. Provide for early ambulation.

2,3,4,5

What should a nurse include when teaching a client diagnosed with shigellosis regarding how to prevent the spread of the infection to others? 1. Wash hands three times a day with alcohol. 2. Do not return to work until authorized by local health department. 3. Do not prepare food for others while you are sick. 4. Avoid swimming until fully recovered. 5. No sex until several days after diarrhea has stopped.

2,3,4,5

A client from a long-term care facility arrives in the emergency department by ambulance with altered level of consciousness. The primary healthcare provider instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client's wrist during the initial assessment. Which immediate action should the nurse take to advocate appropriately for this client? 1. Assist the respiratory therapist to prepare the client for immediate intubation. 2. Attempt to contact the client's family. 3. Notify the primary healthcare provider immediately of the client's DNR bracelet. 4. Notify the charge nurse immediately of the client's DNR bracelet.

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry

A client is admitted to the emergency department following a motor vehicle accident (MVA). The client reports abdominal discomfort, weakness, and nausea. Vital signs: BP 88/52, HR 118/min, RR 24/ min. Which healthcare provider prescription should the nurse implement first? 1. Administer ondansetron 2 mg IV. 2. Insert a foley catheter in order to obtain hourly urinary outputs. 3. Infuse lactated ringers (LR) at 200 mL per hour. 4. Type and cross match for four units of packed red blood cells.

A nurse is caring for an 80 year old client with a total hip arthroplasty (THA) 8 hours ago. Which nursing postoperative intervention has priority for an elderly client. 1. Reorient to time and place 2. Position in an abduction pillow 3. Coughing and deep breathing exercises Q2H 4. Turn the client toward the unaffected side

During a treatment team meeting, a client who recently had a mastectomy shares that she can no longer stand to look at herself in the mirror and does not want her husband to see her without clothes. Which statement by the nurse on the team would be most appropriate? 1. "Try looking at yourself in the mirror 5 minutes four times daily until you feel more comfortable." 2. "I'm sure that your husband loves you just the way you are." 3. "Trying to adjust to the change in your body image must be very hard for you." 4. "You look great! Also, when the swelling goes down, you will look even better!"

How closely monitored is access to a facility's health information system? 1. No monitoring; the system is password protected. 2. Monitored intermittently. 3. Monitored closely and constantly for inappropriate use. 4. Monitored daily and sporadically.

A client with nausea, vomiting, and diarrhea for the past three days has been prescribed one liter of normal saline with 40 mEq (40 mmol/L) of potassium chloride to infuse at 250 mL per hour. Which assessment would the nurse report to the primary healthcare provider prior to initiating the infusion? 1. Blood pressure of 106/54 2. Apical pulse of 112 per minute 3. Tenting of the skin over the sternum 4. Urinary output of 148 mL for the past 6 hours

The family of an elderly client are concerned about emotional well-being since the loss of the spouse two years ago. What alternative therapy could the nurse recommend for this client? 1. Massage 2. Bioelectromagnetics 3. Accupressure 4. Animal-assisted therapy

A client who is scheduled for a total hip replacement surgery in the morning begins to verbalize anxiety related to the surgery. Arrange the client's comments in order as the client's anxiety advances beginning with mild to panic anxiety. "Can I wear my wedding ring during the surgery?" "I know those hip exercises after the surgery are painful." "Having trouble thinking about anything, but the surgeon cutting on my hip." "My Dad died on the operating table, and I keep thinking I will die too."

This is the correct order

A client who is sitting in a chair begins to have a tonic-clonic seizure. In what order should the nurse intervene? Ease client to the floor. Position client on side. Push aside any furniture. Administer prescribed antiepileptic medication.

This is the correct order

A hospitalized client is being prepared for transport to the dialysis unit when the nurse receives new orders for a stat unit of packed red blood cells to be infused. In what order should the nurse implement these actions? Verify client's blood identification arm band is in place. Have dialysis nurse co-sign for the unit of blood. Allow client to proceed to the dialysis unit. Proceed to blood bank and sign out the unit of blood. Advise dialysis nurse that blood is to be infused.

This is the correct order

A nurse has been assigned to care for five clients. In what order should the nurse assess these clients after shift report? Place in priority order from highest to lowest priority. Client hospitalized to rule out abdominal aortic aneurysm who is reporting deep, aching pain in the flank area. Client whose BP is reported by the UAP to be 200/102 at present. Client diagnosed with an arterial ulcer to the right leg who reports pain of 8/10. Client with Buerger's disease reporting numbness, tingling and cold in toes. Client diagnosed with peripheral vascular disease requesting information on smoking cessation.

This is the correct order

What should the nurse teach the mother about appropriate sleep in teenagers? 1. Teens need about 8 to 10 hours of sleep each night. 2. Biological sleep patterns shift toward earlier wakening. 3. Typically do not require as much sleep as adults. 4. Teenagers do not exhibit the normal signs of sleep deprivation.

What actions should the nurse take when administering fentanyl? 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash.

1,2,4

A client is curious about visible appearance changes related to menopause. What menopausal changes, in general, would the nurse explain to the client? 1. Bone loss and fractures. 2. Loss of muscle mass. 3. Improved skin turgor and elasticity. 4. A reduction in waist size.

A nurse notes redness, warmth, and pain at a client's intravenous (IV) insertion site. What does the nurse suspect? 1. Colonization 2. Phlebitis 3. Infectious disease 4. Bacteremia

The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2,3,5

A client is given an intramuscular injection of morphine following a laparoscopic cholecystectomy four hours ago. What client data would best indicate to the nurse that the medication has been effective? 1. Rates pain as 6 on 1-10 scale. 2. Heart rate is within normal limits. 3. Ambulates with assistance of one. 4. Voided 250 mL in 4 hours.

Which nursing action takes priority once a term infant has delivered vaginally? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints

3,4,5,6

A client has received 850 mL of an isotonic solution intravenously in less than 60 minutes. Which central venous pressure (CVP) reading noted by the nurse indicates a problem related to the amount of intravenous fluids infused? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

A client who has right sided weakness and weighs 280 pounds (140 kg) needs to be transferred from the bed to the chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1. Stand at the client's right side. 2. You are physically fit and at lesser risk for injury. 3. Using proper body mechanics will prevent you from injuring yourself. 4. Use the mechanical lift and with another UAP, transfer the client to the chair.

The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? Exhibit 1. aPTT 2. WBC 3. Sed rate 4. K+

When teaching a client about lactose intolerance, what should the nurse include? 1. Common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas. 2. Symptoms of lactose intolerance generally occur three hours after consuming foods high in lactose. 3. Calcium rich foods should be consumed. 4. The client can drink lactose-free milk. 5. Vitamin D foods should be increased in the diet.

1,3,4,5

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma

The nurse is caring for a trauma client who is receiving a unit of whole blood. The client begins to experience lower back pain. What actions should the nurse take? 1. Administer diphenhydramine. 2. Collect a urine specimen. 3. Stop the transfusion. 4. Take the client's vital signs. 5. Change the IV tubing

2,3,4,5

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths

2,4,5,6

A client who had a triple lumen catheter placed in the right subclavian vein 30 minutes ago reports chest discomfort and shortness of breath. The assessment reveals BP 92/58, HR 104, Resp 28, and unequal breath sounds over lung fields. What problem should the nurse suspect this client is exhibiting? 1. Myocardial infarction 2. Atelectasis 3. Pneumothorax 4. Pneumonia

A gunshot victim is brought by ambulance to the emergency room with an open pneumothorax. A bio-occlusive dressing to the chest. The nurse then notes increased dyspnea and sub-q emphysema in the client. What is the nurse's priority action? 1. Prepare client for insertion of chest tube. 2. Apply a non-rebreather with 100% oxygen. 3. Loosen one side of the bio-occlusive dressing. 4. Obtain a tracheostomy kit and call the surgeon.

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals. 5. Get a yearly influenza and pneumococcal vaccination.

3,4

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? 1. Rock to sleep. 2. Place in a baby swing. 3. Provide a pacifier. 4. Swaddle the baby.

A client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." What is the nurse's best response? 1. "That is inappropriate behavior. You will have to go to your room if you say that again." 2. "You've got to be kidding! You can't get me fired for not sleeping with you." 3. "I don't want to hear that again! Don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that they have a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."

A client has been given information about several complementary therapies for the treatment of anxiety disorder. Which therapy selected by the client would require the nurse to check for allergies? 1. Aromatherapy 2. Biofeedback 3. Guided Imagery 4. Acupuncture

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1,2,4,5

A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? 1. PT of 13 seconds 2. PTT of 22 seconds 3. INR of 1.0 4. Hemoglobin of 11 g/dL (6.8266 mmol/L)

An emergency department nurse has just received report on assigned clients. Which client should the nurse assess first? 1. Client reporting back pain of 8 on a scale of 0/10 after falling down from a patch of ice. 2. Client reporting a stiff neck and has a fever of 103 ° F (39.4 ° C). 3. Client vomiting for 3 hours after eating at a restaurant. 4. Client with a history of migraines reporting a severe headache.

The nurse is instructing a client newly diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed omeprazole. What comment by the client indicates to the nurse that the teaching was successful? 1. "I should lay down after eating a big meal." 2. "Spicy food and caffeine might cause me pain." 3. "If the pain gets worse, I should take two pills." 4. "I will take the omeprazole whenever I have pain."

What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn? 1. Administer analgesics. 2. Apply cool water soaks. 3. Check immunization status for tetanus. 4. Educate family to avoid greasy lotions or butter on the burn.

A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? 1. "The cast feels tight on my arm." 2. "There is an odd smell inside my cast." 3. "I can't open up my fingers this morning." 4. "The pain medicine is not relieving my pain."

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 60, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

150 drops/min

The nurse is preparing to hang an IV bottle of fat emulsions 20% on a client. At what rate should the nurse set the IV infusion pump? Answer in numbers only. Exhibit

A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.

A client arrives at the emergency department (ED) in obvious emotional distress, reporting perioral numbness and tingling of the fingers and toes. The nurse notes a respiratory rate is 56/min. What should be the initial intervention performed by the nurse? 1. Send the client for a CT of the head. 2. Place on 100% O2 per non-rebreathing face mask. 3. Have the client breathe into a paper bag. 4. Administer diazepam 2 mg IV push.

A child is admitted to the emergency department due to suspected ruptured appendicitis with perforation. What would be the priority nursing assessment for this client? 1. Monitor for the Rovsing sign. 2. Assess for an increase in temperature. 3. Check for rebound tenderness at McBurney's point. 4. Monitor for increasing pain and rigidity of the abdomen.

A child is brought into the school nurse's office after a fall on the playground which resulted in a nose bleed. What initial action by the nurse is most appropriate? 1. Hold cup under nose and allow fluid to drip. 2. Place an ice pack on the back of the neck. 3. Have child lie down and elevate the feet. 4. Pinch the bridge of the nose for 10 minutes.

A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take? 1. Ask primary healthcare provider for an oral antiemetic. 2. Give ondansetron IVPB with the chemotherapy. 3. Wait until chemotherapy is complete to infuse ondansetron. 4. Stop chemotherapy temporarily and flush line to give ondansetron.

A client 34 weeks pregnant is scheduled for a visit at the prenatal clinic one week after receiving an injection of prenatal betamethasone due to the potential for premature labor. The client had been resting at home all week, as ordered. What assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Blood pressure of 92/50 2. Fasting blood sugar of 75 3. Tympanic temperature of 100º F 4. Muscle weakness with cramping

A client asks the nurse, "How is relaxation therapy going to help reduce my stress?" What would be the nurse's best response? 1. Relaxation therapy leads to more awareness of potential stressors 2. Relaxation therapy reduces stress by releasing small doses of epinephrine into the body. 3. Stress can be eliminated from your life when you use this therapy. 4. Relaxation therapy can counteract the flight or fight response.

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance would be the nurse's priority concern? 1. Hypomagnesemia 2. Hyponatremia 3. Hyperkalemia 4. Hypercalcemia

A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"

A client with a diagnosis of heart failure is observed in Fowler's position states, "I can't get my breath". What is the priority intervention for this client? 1. Dangle the client's legs over the side of the bed. 2. Auscultate anterior and posterior lung fields bilaterally. 3. Call respiratory therapy to the room stat to bring an oxygen mask. 4. Administer PRN morphine sulfate 2 mg IVP via existing venous access device.

A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that procedure. What is the most important action for the nurse to take prior to changing this catheter? 1. Check size of existing catheter and balloon. 2. Ask client when the catheter was last changed. 3. Clamp and empty the present catheter bag. 4. Gather clean gloves and basin of hot soapy water.

Parents of school-aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates adequate understanding of appropriate use of TV in the family? 1. I don't allow my kids to watch violent TV shows. 2. They usually watch the kid shows on the kids' networks. 3. I don't usually worry about the time watching TV on weekends. 4. They can choose one TV show per day without my input.

The nurse is performing a home assessment of a two year old. Which behavior by the toddler does the nurse identify as normal development? 1. Drinks from a cup. 2. Cuts food with a knife. 3. Pours juice into a cup. 4. Eats with a fork.

A client is scheduled to have a Cardiac Positron Emission Tomography (PET). What pre-procedure information should the nurse provide to the client? 1. Avoid caffeinated food and drinks for 24 hours prior to test. 2. Do not eat for 4 to 6 hours before the test. 3. Do not wear jewelry. 4. Take calcium channel blocker prescription the day of the test. 5. Wear comfortable, loose-fitting clothing.

1,2,3,5

A client who has recurrent episodes of allergic rhinitis asks the nurse what could be done to decrease symptoms. What instruction should the nurse provide to this client? 1. Remove pets from interior of home. 2. Treat a stuffy nose with warm salt water. 3. Remove carpeting. 4. Stay inside when pollen count is at its lowest. 5. Wash bed linens in hot water.

1,2,3,5

A client has been admitted to the orthopedic floor following application of a long leg cast for a fractured femur. What nursing action takes priority? 1. Perform neurovascular checks of the extremities. 2. Cover the edge of the cast near the groin area. 3. Instruct client not to insert anything into cast. 4. Use palms of hands to lift and position the cast.

A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? 1. "I feel like food gets stuck in my throat when I eat." 2. "I have a hard time brushing my teeth properly." 3. "My fingers burn when I go outside in the winter." 4. "I get short of breath whenever I exercise."

The primary healthcare provider prescribes 12,000 units of Heparin every 12 hours. The pharmacy dispensed a vial of heparin containing 40,000 units per mL. How many mL will the nurse administer? Round answer using one decimal point.

0.3

A 9 month old with asthma symptomology has montelukast sodium oral granules prescribed. What is the most appropriate way for the nurse to instruct the parent on how to administer the medication? 1. Mix the granules with a spoonful of baby food such as applesauce. 2. Pour the granules directly on the back of the infant's tongue. 3. Dissolve the granules in an 8 ounce (240 mL)bottle of juice. 4. Administer the medication in the morning mixed in a bowl of rice cereal.

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

A client admitted with somnolence has a history of chronic bronchitis and heart failure. Vital signs on admit are T 101.8ºF (38.8ºC), HR 106, R 26/shallow, BP 90/58. ABGs are pH 7.2, PCO2 75, HCO3 26. The nurse determines that this client has which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and cross match. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.

A client becomes progressively cyanotic and unresponsive post central line insertion. Which action should the nurse take? 1. Place the client on the left side with the client's head down. 2. Administer a thrombolytic agent. 3. Auscultate the client's heart sounds. 4. Have the client bear down and perform valsalva maneuver.

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. A private room on the gynocological unit. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

A client diagnosed with cirrhosis is being treated for ascites and increased ammonia levels. Prior to discharge, the nurse reviews dietary instructions. The nurse knows teaching was successful when the client selects what menu plan? 1. High calorie, low protein 2. High protein, low sodium 3. Low calcium, low potassium 4. Low carbohydrates, high fat

A client diagnosed with hypertension has been prescribed metoprolol. Which statement by the client indicates that the client's medication instruction for metoprolol has been effective? 1. "I should not stop taking this drug immediately." 2. "I will need to rinse my mouth with water 3 times a day." 3. "I can decrease my aerobic exercises from 3 to 2 times per week." 4. "I will report irregular heartbeats, if they continue for more than 3 days."

A client diagnosed with pancreatic cancer is being discharged home to live with an adult child. What action should the nurse take to promote continuity of care? 1. Identify community services available for the client and family. 2. Refer client for hospice care. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.

A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do? 1. Monitor intake and output and daily weight. 2. Allow for frequent, uninterrupted rest periods. 3. Institute seizure precautions. 4. Protect client from injury that may cause bleeding.

A first time mother-to-be shares with the nurse a sense of indifference towards the impending birth of the infant. The client is concerned about "being a good mother" because of current lack of interest. What response by the nurse would be most appropriate at this time? 1. Such feelings are not unusual for first time mothers." 2. "Once you hold your new baby, you will be just fine." 3. "Would you like to discuss this problem with the doctor?" 4. "Describe the fears you have regarding your new baby."

A five year old is in kindergarten and goes to the nurse's office where she reports a "stomachache". While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? 1. Ask the student about the bruises on the arms and ears. 2. Do nothing as bruises are common in 5 year old children. 3. Report the injuries immediately to the parents. 4. Discuss the findings with the child's teacher.

A night nurse is receiving report from the day nurse when the day nurse states, "I have an appointment and I need to leave. Can you get the rest of the client's information from the medical records?" What client right may be compromised by the day nurse's request? 1. Reasonable continuity of care 2. Confidentiality 3. Considerate and respectful care 4. Participation in decision making

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, wwhen they ask about your client care. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea

After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/VN how the client assignment should be adjusted. 2. Assign one of the LPN/VN's clients to another nurse. 3. Encourage the LPN/VN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? 1. Adaptive and coping skills for dealing with loss 2. Intellectual capacity to make personal decisions 3. Socioeconomic status for independent living 4. Spiritual awareness for emotional comfort.

An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

An experienced RN and LPN are working with a new nurse who has just recently passed NCLEX®. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important for consideration when delegating? 1. Lack of experience of the new nurse. 2. The preferences of the LPN who has experience. 3. RN's desire to avoid confrontation. 4. Assignment of equal number of clients to the RN, LPN and new nurse.

An older adult client is experiencing ongoing fecal incontinence with 6-7 small, brown, liquid stools each day. The client eats a regular diet, does not receive any stool softeners or laxatives, and sits in the wheelchair for 2 hours twice a day. What underlying cause of the liquid stools should a nurse suspect? 1. Fecal impaction 2. Gastrointestinal virus 3. Inadequate roughage in the diet 4. Inactivity from sedentary lifestyle

Because of over-crowding, the charge nurse of a busy unit has been instructed to place two clients in each private room. An elderly client with early dementia is currently in one of the private rooms recovering from pneumonia. The nurse knows what client would make the most appropriate roommate? 1. A young adult for evaluation of severe recurrent migraines. 2. An adolescent s/p appendectomy going home tomorrow. 3. A terminal adult client admitted for pain management. 4. A bipolar client in the manic phase of major depression.

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

The adult child of a client diagnosed with bipolar disorder asks the nurse if they will one day be diagnosed with the same disorder. What is the nurse's best response? 1. "There is a familial tendency for developing this disorder; however, it doesn't mean you will definitely develop this disorder." 2. "You should not worry about developing this disorder. You are young and healthy." 3. "If you were going to develop this disorder, you would have it by now." 4. "You have not been exposed to anything that would contribute to the development of this disorder, so you will not develop this disorder."

The charge nurse is assigning an unlicensed assistive personnel (UAP) to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. Client with thrombocytopenia. 2. Client with a fractured femur. 3. Client with an inguinal hernia. 4. Client with irritable bowel syndrome.

The charge nurse walks into the client's room as the staff nurse is preparing the client for discharge. The charge nurse overhears the staff nurse giving the client her phone number. The staff nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do first? 1. Interrupt the staff nurse and complete the discharge. 2. Tell the staff nurse in the client's presence that the action is inappropriate. 3. Make no comment, and let the staff nurse continue to talk with the client. 4. Stay with the client until ready to leave the unit.

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.

The client is being admitted for a myocardial infarction (MI). Which assessment finding is expected? 1. Reports of nausea and vomiting 2. Elevated temperature higher than 102 degrees F (38.89 degrees C) in the first 24 hours. 3. Pain relieved by two aspirin tablets. 4. Myoglobin will be negative.

The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud.

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? 1. Not permissible because the housekeeper is not medical personnel. 2. Is permissible since the housekeeper does help care for the neighbor. 3. Not permissible despite family stating housekeeper is "like family". 4. Is permissible given that no other family members are available now.

The nurse assesses bruises on a child's face, the hands, and the feet. When questioned, the parents state their child is so clumsy. What action by the nurse demonstrates client advocacy? 1. The nurse reports the incident to the Child Protective Services. 2. The nurse notifies the parent's clergy. 3. The nurse reports the assessment to the primary healthcare provider. 4. The nurse speaks to the parents privately about any concerns.

The nurse in the emergency department is caring for a client admitted in diabetic ketoacidosis (DKA). Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 12 mm of Hg

The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bipolar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.

The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/L (2.4 mmol/L) this morning. How should the nurse proceed? 1. Notify the primary healthcare provider of the potassium level immediately. 2. Administer the medications as scheduled and notify the primary healthcare provider on rounds. 3. Give the potassium, but hold the furosemide until primary healthcare provider rounds. 4. Assess the client for muscle cramps.

The nurse is performing a Denver Developmental Screening Test II on a 4 ½ year old. What behavior should the nurse expect the child to demonstrate? 1. Prepares own cereal without help. 2. Correctly copies a square. 3. Draws a person with at least 5 body parts. 4. Balances on each foot for more than 6 seconds.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

The school nurse suspects that a 5 year old has been physically abused. What would be the best way for the nurse to establish trust with this child? 1. Using play therapy. 2. Asking the mother to come to the school. 3. Hugging the child. 4. Conducting an in-depth interview with the child.

Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit (CDU). What action should the nurse take? 1. Document the findings. 2. Notify the primary healthcare provider. 3. Decrease the amount of suction. 4. Use a padded hemostat to clamp the chest tube.

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur.

Which action by a nurse would require the charge nurse to intervene? 1. Walking in the hallway outside the operating room without a hair covering. 2. Putting on a surgical mask, gown and cap shoe cover before entering the operating room (OR). 3. Wearing a surgical mask into the holding area. 4. Wearing scrubs from home into the nursing station.

Which client could the telemetry charge nurse safely transfer in order to admit a new client? 1. Twenty-four hour post operative carotid endarterectomy. 2. Unstable angina with onset of atrial fibrillation. 3. Status post coronary artery bypass grafting (CABG) with atrial flutter. 4. Myocardial infarction with a history of heart failure.

Which client should the nurse assess first? 1. Client who reports increasing size, firmness, and discomfort in the abdomen. 2. Client who develops a headache and dizziness after being started on losartan. 3. Client with a chest tube whose pulse oximeter reading is 92 mmHg while on 2 liters of oxygen per nasal cannula. 4. Client who is receiving total parenteral nutrition (TPN) and has a blood glucose level of 140 mg/dL (7.8 mmol/L).

Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease 3. 66 year old client with angina scheduled for a cardiac catheterization this AM 4. 78 year old client who had a left hemispheric stroke 4 days ago

Which comment made by a new nurse regarding calcium gluconate 1000 mg (10 mL) IV indicates to the charge nurse that further education is needed? 1. "Infusion rate should be 5 mL/minute." 2. "Calcium gluconate will counteract the effects of the client's hyperkalemia." 3. "I will monitor for hypophosphatemia after administering this medication." 4. "This medication is given to reverse the effects of hypermagnesemia."

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer? 1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian

Which postpartum client should the nurse assign to a private room? 1. Has antibodies for Hepatitis C. 2. Is rubella non-immune. 3. Is rubella immune. 4. Has lupus antibodies.

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

1,2,3,4

A pediatric nurse is providing anticipatory guidance to a group of parents who have children nearing the age of 1 year old. What milestones should the nurse teach the parents to expect to see in their 1 year old child? 1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing. 3. Able to say several single words. 4. Pulls toys while walking. 5. Builds a tower of 4 blocks.

1,2

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1,2

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? 1. Orthopnea. 2. Paroxysmal nocturnal dyspnea. 3. Petechiae on the trunk. 4. Increasing CVP with decreasing BP. 5. Pericardial friction rub. 6. Widening pulse pressure.

1,2

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children to receive at 6 months? 1. Diphtheria 2. Hib 3. Influenza 4. Measles 5. Mumps 6. Rubella

1,2,3

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1,2,3

The nurse manager is planning a leadership development workshop for new charge nurses. Which components of the communication cycle should the manager include as necessary for effective verbal communication? 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

1,2,3

The palliative care nurse is instructing the family of a client who is experiencing nausea and vomiting on methods of controlling these symptoms. What methods should the nurse include? 1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client 3. Provide light, bland food. 4. Drink liquids less often 5. Chew 5-30 paw paw seeds

1,2,3

What information should be included in the health promotion plan for parents regarding the promotion of adequate bowel elimination in their toddler? 1. Include adequate fiber in the diet through whole grains and fruits. 2. Increase intake of water daily. 3. Provide toileting opportunities that are free from distractions. 4. Encourage the toddler to go to the bathroom at least three times daily. 5. Take away attention from the toddler unable to potty.

1,2,3

What should the nurse include about transmission of the chickenpox virus while teaching a group of parents about the importance of vaccination? 1. Direct contact 2. Indirect contact 3. Airborne 4. Droplet 5. Common vehicle

1,2,3

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? 1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position 5. Place ice packs under axilla for fever greater than 101°F (38.3°C)

1,2,3,4

A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min

1,2,3,4

A nurse is planning an educational session on safety for parents of young children. What safety points should the nurse include? 1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. 5. Vitamins should be referred to as candy so that children will take them. 6. A child at age 7 may sit in the front seat of a car.

1,2,3,4

A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? 1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test. 5. Test near vision with the Snellen chart.

1,2,3,4

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? 1. Asterixis 2. Lethargy 3. Amnesia 4. Behavioral changes 5. Kussmaul respirations

1,2,3,4

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level altitude

1,2,3,4

The nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complementary and/or alternative therapies? 1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki 5. Zumba

1,2,3,4

What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? 1. Document current functional status assessment 2. Notify the primary healthcare provider of transfer completion. 3. Transfer essential medical record to the receiving facility. 4. Phone report to the receiving nurse. 5. Send a day's worth of medications with the client to the receiving facility.

1,2,3,4

What strategies for smoking prevention could the school nurse recommend to the community task force? 1. Have a "Pledge Campaign" asking students not to use tobacco. 2. Include effects of smoking in health classes. 3. Enlist help from celebrities who are against smoking. 4. Conduct a "Don't Smoke" poster contest aimed at seventh graders. 5. Start a smoking cessation class for students who currently smoke.

1,2,3,4

What test should the nurse use to test a client's gross hearing acuity? 1. Weber's 2. Rinne 3. Audiometry 4. Whisper 5. Monofiliment testing

1,2,3,4

A 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations should the nurse suggest the client discuss with the primary health care provider? 1. Meningococcal conjugate vaccine 2. Tdap vaccine 3. HPV vaccine 4. Seasonal flu vaccine 5. Hepatitis B 6. Polio

1,2,3,4,5

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client? You answered this question Incorrectly 1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils 6. Large button closures on clothes

1,2,3,4,5

A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? 1. Blood pressure screening 2. Glucose monitoring 3. Influenza vaccination 4. BMI calculation 5. Test urine for protein. 6. Pneumococcal vaccination

1,2,3,4,5

An occupational health nurse works in a factory where loud equipment is used in production of the factory's product. What should the nurse emphasize to factory management persons to reduce the risk of hearing impairment? 1. Supply workers with earplugs when exposed to noise. 2. Replace high noise machinery with low noise machinery. 3. Limit amount of time a person spends at a noise source. 4. Operate noisy machines during shifts when fewer people are exposed. 5. Supply personal noise monitoring to identify employees at risk from hazardous level of noise. 6. Have all employees make an appointment for a hearing test.

1,2,3,4,5

The nurse providing palliative care to a client would include which outcomes in the teaching plan? 1. Maintaining the client's quality of life 2. Minimizing family caregiver stress 3. Managing the client's pain 4. Managing the client's and family's emotional needs 5. Attending to the client's spiritual needs

1,2,3,4,5

Which clinical manifestations would a nurse expect to find in a client who has sustained a flail chest injury? 1. Dyspnea 2. Crepitus 3. Paradoxical chest wall movement 4. Chest pain on inspiration 5. Shallow respirations 6. Bradycardia

1,2,3,4,5

Which vaccines would a nurse participating at a health fair encourage a 65 year-old adult to receive? 1. Influenza 2. Herpes Zoster 3. Diphtheria 4. Pertussis 5. Pneumococcal vaccine 6. Measles, mumps, and rubella (MMR)

1,2,3,4,5

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care? 1. Elevate head of bed to a semi-fowlers position. 2. Monitor the color of urine and stools. 3. Turn every 2 hours. 4. Instruct about a 1200 calorie diet. 5. Monitor creatinine levels daily.

1,2,3,5

A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring.

1,2,3,5

A home health nurse is planning home safety education for a client and spouse. Which actions should be included to promote fire safety in the home setting? 1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and a place where all family members will meet.

1,2,3,5

A nurse is planning to provide information to a group of adults considering smoking cessation. What information should the nurse include? 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

1,2,3,5

A school nurse is planning a session on the effects of cannabis use for a high school health class. Which information does the nurse need to include? 1. Cannabis ingestion can cause tachycardia. 2. Inhaled cannabis produces a greater amount of tar than tobacco. 3. Cannabis smoke contains more carcinogens than tobacco smoke. 4. Cannabis ingestion reduces the risk for heart disease 5. Orthostatic hypotension can be caused by cannabis ingestion.

1,2,3,5

An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.

1,2,3,5

The nurse is caring for a client who receives hemodialysis three times a week. What dietary education should the nurse provide for this client? 1. Increase protein intake 2. Restrict fluids 3. Decrease sodium 4. Increase phosphorus 5. Decrease potassium

1,2,3,5

What discharge education should a nurse provide to a client post hip replacement with a metal joint? 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

1,2,3,5

Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele? 1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 4. Decrease in a feeding by 30 mL 5. Projectile vomiting

1,2,3,5

A medication has been prescribed to be administered through a medication or drug-infusion lock (intermittent peripheral venous access device). The nurse would implement which nursing interventions prior to administering an intravenous (IV) medication through a medication infusion lock? 1. Identify the client 2. Flush the medication lock with normal saline 3. Aspirate the medication lock for blood return 4. Clamp the IV tubing while flushing with saline 5. Verify the administration dosage of the medication 6. Assess the intravenous site for inflammation or infiltration

1,2,3,5,6

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1,2,3,5,6

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 4. Decreased sensitivity to sound. 5. Inability to taste. 6. Numbness of affected side of face.

1,2,3,5,6

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.

1,2,4

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.

1,2,4

The nurse has been teaching the parents of a child taking methylphenidate for the treatment of attention deficit hyperactivity disorder (ADHD). Which comments by the parents indicate adequate understanding of the important considerations for methylphenidate? 1. "I know that I need to monitor weight." 2. "I am supposed to call if my child has decreased attentiveness." 3. "This medication may cause increased drowsiness." 4. "I know that I need to monitor my childs height." 5. "If my child can't sleep, the dosage may need to be increased."

1,2,4

What should the nurse include in the teaching plan for a client who has iron deficiency anemia? 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.

1,2,4

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1,2,4,5

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? 1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 3. Write nurses up when pain level scale is not utilized. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.

1,2,4,5

A nurse works in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? 1. Keep the OR doors closed during a surgical case. 2. Minimize traffic in the OR. 3. Ensure the room has negative air flow. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

1,2,4,5

A school nurse is planning to teach kindergarten students about oral health. Which points should the nurse include? 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

1,2,4,5

An alcoholic client has agreed to take disulfiram 250 mg PO daily. The nurse recognizes that education has been successful when the client makes which statements? 1. "If I decide to stop taking disulfiram, I should not ingest any alcohol for at least 2 weeks or I will have a reaction." 2. "I must read labels carefully so that I know that alcohol is not an ingredient." 3. "I am allowed to eat chili made with beer since the alcohol evaporates from the chili with prolonged cooking." 4. "This medication is not a cure. I still need to attend therapy sessions." 5. "I should avoid eating a lot of chocolate while on this medication."

1,2,4,5

The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests? 1. AST 2. Alkaline phophatase 3. Complete blood count 4. Serum cholesterol levels 5. Serum triglyceride levels

1,2,4,5

What lab values should the nurse monitor when caring for a client diagnosed with acute leukemia? 1. Hemoglobin 2. Hematocrit 3. Lactate dehydrogenase (LDH) 4. Platelets 5. White blood cells 6. Metanephrine

1,2,4,5

A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet. 1. Grilled eggplant 2. Purple grape juice 3. Bacon 4. Cashews 5. Skim milk 6. Salmon

1,2,4,5,6

What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with a diagnosis of bacterial meningitis? 1. Positive Kernig's sign 2. Positive Brudzinski's sign 3. Presence of Babinski's reflex 4. Photophobia 5. Severe headache 6. Nuchal rigidity

1,2,4,5,6

A 3-year-old child refuses to take a prescribed medication. Which statements by the mother, regarding the child's refusal, indicate to the nurse that parental education is needed? 1. "My child is trying to make me angry". 2. "I feel like such a bad mother when my child acts this way". 3. "I promise my child a reward for taking medicine". 4. "I am unfazed by my child's actions". 5. "My child doesn't have to take medicine if he doesn't want to".

1,2,5

A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves

1,2,5

The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? 1. Check to see if client is biting ET tube. 2. Examine tubing for presence of water. 3. Inspect for any loose connections. 4. Reduce the amount of PEEP used. 5. Assess client's need for suctioning.

1,2,5

The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others.

1,2,5

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1,2,5

The nurse is preparing discharge teaching for a client diagnosed with peripheral vascular disease (PVD). Which teaching points should the nurse include about foot and leg care? 1. Wear soft cotton socks 2. Avoid hot whirlpools 3. Rub feet dry 4. Wash feet every other day 5. Clear pathways in house

1,2,5

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? 1. Diarrhea 2. Increased urination 3. Dilated pupils 4. Tachycardia 5. Nausea and vomiting

1,2,5

Which statements by an older adult indicate that teaching about adequate nutrition and hydration have been effective? 1. "Taking a multivitamin every day will help me get enough calcium and vitamin C." 2. "Enrolling in Meals on Wheels will provide me with a nutritious meal every day." 3. "I am less likely to become constipated if I increase my fiber intake to 20 grams a day." 4. "Drinking 1 liter of water a day will keep me hydrated." 5. "I will strive to eat at least 5 servings of fruits and vegetables a day."

1,2,5

A client with diabetes mellitus has a newly prescribed insulin pump. Which statements made by the client indicate understanding of an insulin pump? 1. "I will attach the pump to my waistband or wear it in the pocket of my pants." 2. "I can eat whatever I want as long as I cover the calories with sufficient insulin." 3. "I may take my insulin pump off when I exercise." 4. "I need to check my blood glucose level several times a day." 5. "I have to change the catheter at the end of the pump every week."

1,3,4

A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.

1,3,4

What action by the unlicensed assistive personnel (UAP) would require the nurse to intervene? 1. Returning clean unused linens for a client to the linen supply closet. 2. Tying the linen bag securely and tightly at the top. 3. Filling the linen bag with as much soiled linen as possible. 4. Shaking linens after removing from the bed to check for personal items. 5. Washing hands after removing linens from the bed.

1,3,4

What intervention should the nurse initiate when caring for a child following a tonsillectomy and adenoidectomy? 1. Avoid fluids with a red or brown color. 2. Regular suctioning of the mouth and throat. 3. Administer pain medication around the clock. 4. Apply ice collar to the front of the neck as needed. 5. Encourage coughing and deep breathing every two hours.

1,3,4

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.

1,3,4

Which assessment findings would the nurse expect when assessing a client for dementia? 1. Slow progressive deterioration of cognitive functioning 2. Decreased level of consciousness 3. Personality changes 4. Difficulty paying attention 5. Suicidal thoughts and sadness

1,3,4

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1,3,4

A client diagnosed with hypothyroidism has been taking levothyroxine in increasing doses over the past week. Which findings, if present, would indicate to the nurse that the drug dosage is too high? 1. Irritability 2. Weight gain 3. Tachycardia 4. Tremors 5. Headache 6. Bradycardia

1,3,4,5

An elderly client with congestive heart failure (CHF) is admitted from the ER. The nurse is attempting to obtain an oxygen saturation reading using a pulse oximeter but the probe will not record. What actions could the nurse implement in order to determine the oxygen saturation level? 1. Use an earlobe for placement of the probe. 2. Place on the upper arm, utilizing an automatic cuff. 3. Remove any fingernail polish before attaching probe. 4. Place fingers in warm water before checking sat level. 5. Don't use fingers on same arm as an automatic cuff.

1,3,4,5

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1,3,4,5

The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.

1,3,4,5

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.

1,3,4,5,6

Which nursing action represents measures taken to protect the client from a mode of infection transmission in the chain of infection? 1. Donning personal protection equipment. 2. Administering the Haemophilus influenzae type B (HIB) immunization to a child. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 5. Teaching importance of long pants and sleeves and insect repellent to reduce the risk of West Nile Virus. 6. Performing hand hygiene after removal of soiled gloves.

1,3,4,6

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? 1. "The best way to prevent HIV is to abstain from sex." 2. "Contraceptives should contain spermicide N-9." 3. "Douching is recommended after intercourse." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

1,4,5

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN/VN to the floor. Which clients would be appropriate assignments for the LPN/VN? 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1,3,5

A nurse enters the operating room (OR) with artificial fingernails in place. What should the charge nurse explain to the nurse? 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn in the OR. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of surgical site infection to the client. 4. A more vigorous scrub is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.

1,3,5

A nurse is planning to provide education to a client wishing to breastfeed. What instructions should the nurse include when teaching this client? 1. Apply warm compresses to breast just prior to breastfeeding. 2. Establish a routine for breastfeeding. 3. Massage breasts during feeding. 4. Wear well-fitting bra continuously for first 24 hours after birth. 5. Wash hands before breastfeeding.

1,3,5

The nurse is caring for a client who has an active herpes simplex 1 lesion on the lip. What measures should be implemented by the nurse? 1. Tell the client to avoid touching the lesion. 2. Scrub the lesion gently with soap and water prior to meals. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 4. Wear sterile gloves when applying medication to lesion. 5. Ask client to discard lip balm until lesion is resolved.

1,3,5

The nurse is observing a new nurse explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new nurse understands the phototherapy process when what statements are made to the mother? 1. "The infant's eyes must be covered throughout the light session." 2. "The heat from the light may cause some harmless swelling in arms." 3. "Body temperature must be checked frequently to monitor for fever." 4. "It is important to restrict feedings during the phototherapy sessions." 5. "We check bilirubin levels several times daily to be sure it's decreasing."

1,3,5

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

1,3,5,6

A client has been admitted to the medical unit after sustaining a stroke. The admitting nurse initiates a nursing diagnosis of unilateral neglect related to a decrease in visual field and hemianopia from cerebrovascular problems as evidenced by consistent inattention to stimuli on the affected side. What nursing interventions should the nurse initiate for this client? 1. Instruct client to scan from left to right to visualize the entire environment. 2. Encourage client to practice exercises independently. 3. Position bed in room so that individuals approach the client on the unaffected side. 4. Apply splints to achieve stability of affected joints. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

1,3,5,6

A client is being admitted to the hospital for possible appendicitis. During the admission history and physical, the client reports having fatigue and trouble concentrating. What other client statement during the assessment would lead the nurse to suspect marijuana use? 1. "My eyes have looked bloodshot lately." 2. "I've noticed that my appetite has been decreasing." 3. "I sometimes feel that I am off balance." 4. "I have been losing weight lately." 5. "I don't have the desire to do the things I used to do." 6. "My heart seems to beat fast a lot of the time."

1,3,5,6

The nurse is caring for a client being treated for hypertensive crisis and suspects that the client may be developing an abdominal aortic aneurysm (AAA). Which assessment findings by the nurse suggest that the client is developing this complication? 1. Abdominal bruit 2. Upper back pain 3. Hoarseness 4. Pulsations around umbilicus 5. Shortness of breath

1,4

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include? 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.

1,4

A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

1,4,5

A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.

1,4,5

The charge nurse is delegating assignments on the Alzheimer's unit of a long-term care facility. What task could be assigned to the unlicensed assistive personnel (UAP)? 1. Replace soiled heel protectors on bedfast client. 2. Provide TUMS to client reporting heartburn. 3. Trim fingernails on confused diabetic client. 4. Escort dementia client on an outdoor walk. 5. Assist client to complete the daily menu list.

1,4,5

The nurse is caring for a client admitted with heart failure. Which prescriptions would necessitate that the nurse seek clarification from the primary healthcare provider? 1. Furosemide 20.0 mg p.o. daily 2. Rosuvastatin 5 mg p.o hs 3. Digoxin 0.125 mg IVP every 8 hours for three doses 4. Folic acid 1 mg daily 5. Heparin 1000 IU subcutaneously daily

1,4,5

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Assist client to brush and floss teeth. 2. Administer sodium polystyrene sulfonate enema. 3. Evaluate pain relief after narcotic administration. 4. Measure urine output when client voids. 5. Gather supplies to prepare room for isolation. 6. Monitor client for pain while assisting with ambulation.

1,4,5

A client diagnosed Alzheimer's disease has been prescribed memantine. What should the nurse teach the caregiver about this medication? 1. When beginning this medication provide ambulatory assistance. 2. This medication is prescribed to help improve mild dementia. 3. This medication must be taken without food. 4. If a dose is missed, double the next dose. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

1,5

A client diagnosed with heart failure has been prescribed a 2 gm sodium diet. Which food choices selected by the client would indicate to the nurse that the client understands this diet? 1. Pork loin 2. Frozen cheese ravioli dinner 3. Instant vanilla pudding 4. Thin crust pepperoni and ham pizza 5. Fresh salad with fresh citrus juice dressing 6. Bottled tomato juice

1,5

A young adult diagnosed with schizophrenia is admitted to the crisis center with exacerbation of psychotic behaviors. The client responds well to a medication regime of chlorpromazine three times daily. The nurse is reviewing discharge instructions and knows teaching was successful when the client makes what statements? 1. "This medication will help me control my behavior." 2. "I should take this medication only if I feel anxious." 3. "I need to have blood levels checked periodically." 4. "My medication will eventually cure my disorder." 5. "I must apply sunscreen and wear a hat if outside."

1,5

The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include? You answered this question Incorrectly 1. Use moisturizer daily on dry skin. 2. Massage reddened skin areas. 3. Prevent shearing by maintaining the head of bed at 45 degrees or higher. 4. Place rubber ring (donut) under client's sacral area. 5. Position client at 30 degree tilt when placed on side.

1,5

The nurse is teaching a group of parents how to promote healthy teeth in their newborn. What should the nurse include? 1. Clean gums with a damp washcloth after feedings. 2. Use a firm-bristled toothbrush once teeth have erupted. 3. Beginning at birth use toothpaste the size of a pea. 4. Allow only milk bottles in bed. 5. Wean from bottle by 15 months.

1,5

When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information

1,5

While completing the nutritional history of a client admitted with pernicious anemia, the nurse determines that the client follows a strict vegan diet. What education should the nurse provide to the client? 1. Vitamin B12, a nutrient needed to prevent pernicious anemia, is found in some foods like meat, fish, eggs, and milk. 2. In order to increase intake of vitamin B12, your diet must contain beef or chicken liver at least once per week. 3. In addition to eating plants, you should eat dairy products and eggs in order to prevent pernicious anemia. 4. Vegetables high in protein include cabbage, carrots and squash. 5. Pernicious anemia occurs when the body produces red blood cells that are larger than normal and result in a lower than normal red blood cell count.

1,5

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.

1,6

The nurse is performing a routine history and physical on a client who attends the Senior Citizen's Center. What finding noted by the nurse would suggests that the client may have a history of chronic emphysema? 1. Barrel chest 2. Green sputum 3. Kyphosis 4. Tracheal deviation 5. Resonance to percussion of bilateral lung fields 6. Reports frequent morning headaches

1,6

A primary healthcare provider has prescribed chlorpromazine 150 mg by mouth twice a day. The pharmacy sends chlorpromazine oral concentration: 100 mg/mL. How many mL should the nurse administer for each dose? Round answer using one decimal point.

1.5

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

A client has been admitted for observation after having a minor automobile accident. During the admission history, the client admits to being an alcoholic. Two hours after admission the nurse notes the client's cardiac rhythm displayed on the telemetry monitor. The client reports shortness of breath, chest discomfort, and nausea. What initial action should the nurse take? Exhibit 1. Cardiovert at 200 joules. 2. Administer magnesium 1 gm IVP over 30 seconds. 3. Begin cardiopulmonary resuscitation (CPR). 4. Obtain a 12 lead ECG.

A client has been admitted with a diagnosis of sepsis and two sets of blood cultures have been ordered. When the nurse explains the procedure, the client asks the purpose of drawing blood from two different veins at two different times. What is the best response by the nurse? 1. "If we don't get enough blood the first time, we can obtain more." 2. "We want to be sure to get samples of all organisms in your blood." 3. "We have to be certain none of the samples have been contaminated." 4. "It's important not to get too much blood from the arm all at once."

A client has been trying to implement a low fat diet for prevention of heart disease and enhancement of weight loss. He further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? 1. Suggest that the client prepare all meals at home. 2. Schedule a meeting with husband and wife to discuss diet and health. 3. Suggest that the client limit intake to one serving of each food at meals. 4. Ask the client to give his wife a cookbook with low fat recipes.

A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 1. Sit quietly with client and allow expression of feelings. 2. Instruct UAP to take mother to the NICU immediately. 3. Request hospital clergy to visit the mother right away. 4. Notify father of the baby about the current situation.

The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer? 1. Diagnosed with irritable bowel syndrome 2. Has a family history of colon polyps 3. Diagnosed with cirrhosis of the liver 4. Has a history of colon surgery

A client has received discharge education post extracapsular cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "A protective eye patch will be needed for 24 hours." 2. "I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal." 3. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." 4. "When sleeping, I will avoid lying on the same side of my affected eye."

A client is prescribed phenobarbital to control seizures. Which medication prescribed for the client would the nurse recognize interacts with phenobarbital? 1. Lovastatin 2. Loratadine 3. Lansoprazole 4. Lactulose

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the group leader about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.

A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.

A client reports to the nurse, "I just do not feel well. Something is wrong." The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next? 1. Administer PRN anxiolytic. 2. Connect to oxygen saturation monitor. 3. Reassure the client that everything is okay. 4. Instruct on relaxation technique.

A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which nursing intervention should the nurse implement? 1. Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Immediately inform the primary healthcare provider that the client requests additional information about the bronchoscopy procedure. 3. Give the client an information pamphlet on the bronchoscopy procedure, and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.

A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses the procedure. What is the nurse's priority at this time? 1. Administer pre-op sedation to help the client relax. 2. Notify the primary healthcare provider of the client's refusal. 3. Remind the client that the consent is already signed. 4. Ask the family to help convince the client to re-consider.

A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm.

A client with a diagnosis of endocarditis and a new peripherally inserted cential catheter (PICC) line has been discharged home to receive daily intravenous antibiotics for six more weeks. The home health nurse is making an assessment visit today. What instruction by the nurse is most important initially? 1. Take antibiotics before dental procedures. 2. Brush and floss teeth at least twice daily. 3. Report any flu like symptoms immediately. 4. Include rest periods throughout the day.

A client with a history of cardiac disease has safely delivered a full term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement? 1. "Now that the baby is born, I can eat more salt." 2. "I must include lots of fiber to prevent constipation." 3. "I should return to my previous dose of cardiac medication." 4. "I will need extra fluids to help with breast feeding needs."

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look very pretty so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

A clinic nurse completed teaching the parents of a 9 month old baby how to prevent otitis media infections in their baby. Which statement by the parents indicates to the nurse that further teaching is necessary? 1. "Our baby should sit up for feedings." 2. "It is fine to prop up a juice bottle for our baby to drink at night." 3. "Since our baby has ear tubes, ear plugs should be worn when swimming." 4. "We need to keep our baby away from people who are smoking."

A community health nurse is presenting a seminar to teen parents on the topic of infant safety. What priority topic presented by the nurse represents the leading cause of injury or death among infants? 1. Monitoring the infant for food allergies. 2. Placing the infant in rear-facing, approved car seat. 3. Never propping bottle to feed when infant is alone. 4. Positioning infant prone when sleeping or napping.

A community health nurse prepares a presentation about decreasing the risk of the spread of influenza in the community. Which information should the nurse include in the presentation? 1. The flu is spread via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing. 3. Tissues are the most effective means to decrease the spread of the influenza. 4. Antibiotics are effective in treating influenza.

A home health nurse is caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family that the curandero is not a reliable healthcare option.

A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

A nurse has provided postpartum discharge instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? 1. "I will relax and contract my pelvic floor muscles 10 times, eight times a day." 2. "Driving is permitted in one week if I am pain free." 3. "Lifting anything heavier than my baby is not advised." 4. "I will not cross my legs while sitting."

A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. One year old child who has a heart rate of 150 bpm and is crying 2. Two year old child who has a heart rate of 165 bpm and is being rocked 3. Five year old child who has a heart rate of 100 bpm and is playing quietly 4. Thirteen year old adolescent who has a heart rate of 90 and is watching television

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

A preschooler has been hospitalized for observation. The unlicensed assistive personnel (UAP) offers to sit with the child and asks the nurse to suggest an appropriate activity. The nurse knows the best activity choice for a preschool child is what? 1. Children's television show 2. Small stacking blocks 3. A checker board game 4. Children's card game

A primigravida client at 35 weeks gestation has been diagnosed with human papillomavirus (HPV). The nurse knows that the most important information to discuss with this client is what? 1. The infant will not be able to breast feed. 2. The mother will need frequent follow up Pap smears. 3. The fetus will need to be delivered by C-section. 4. The mother must start metronidazole immediately.

A psychiatric client calmly approaches the day nurse stating, "I almost died in my sleep." What response by the nurse would be most therapeutic for the client? 1. "How do you know what happened in your sleep?" 2. "Tell me how you felt when that situation occurred." 3. "You seem to have recovered very well since then." 4. "Are you sure it wasn't just a really bad dream?"

A schizophrenic client tells the nurse, "The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain." What is the nurse's best response? 1. The voice you heard is because of your illness and will go away in time. 2. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. 3. I find it hard to believe that you have talked to the President of the United States. This is not the White House! 4. I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices.

A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack occurs. What would be the nurse's best response to the client? 1. "I understand that you feel anxious. But you must stop this behavior." 2. "The feelings that you described can occur in individuals with asthma. You may find that learning relaxation exercises may help." 3. "I am concerned that feeling anxious during an asthma attack means you need more education about asthma." 4. "Everyone with asthma experiences tough times with their symptoms. You are learning to manage your asthma."

An elderly client diagnosed with terminal cancer is the sole caregiver to a developmentally delayed adult child. The client is worried that the child, with a developmental age of seven years old, will need permanent placement in a long term care facility. What statement by the nurse is most accurate? 1. "Your child will need to be under constant supervision." 2. "A supervised group home would be an ideal setting." 3. "Maybe we could find someone to take in your child." 4. "We should start getting the child used to living alone."

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Call the primary healthcare provider to change the order. 4. Break the capsule in half using a pill splitter.

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

An elderly client is admitted with a severe urinary tract infection (UTI) and is started on IV ertapenem. The nurse returns to the room five minutes after starting the IV antibiotic. What comment indicates to the nurse the client may be experiencing an allergic reaction to the medication? 1. "My hand is burning where the IV is." 2. "My ring is beginning to feel very tight." 3. "I have pain when I go to the bathroom." 4. "I am starting to feel sick in my stomach."

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.

Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse's priority action immediately after the intubation? 1. Suction to clear all secretions 2. Listen for bilateral breath sounds 3. Secure the endotracheal tube 4. Obtain x-ray to verify tube placement

How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.

Staff notifies the nurse that a client receiving tube feedings has increased liquid stool with new rectal excoriation. Following an assessment, the nurse is most concerned about what additional symptom? 1. Reports feeling increasingly tired. 2. Trousseau's sign noted when taking blood pressure. 3. Increased resistance to care activities. 4. Reports abdominal cramping.

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? 1. Facial flushing 2. Reports shortness of breath 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg

The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do? 1. Tell the client that the behavior is inappropriate. 2. Accompany the client to the TV room on the unit. 3. Allow the male client to handle the situation. 4. Continue with the unit routine.

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.

The day shift nurse in a long-term care facility has been noticing that the adult brief on a total-care client has not been changed since the previous day's shift and perineal care has not been provided, despite the brief being full with urine and feces. The client's perineal area is becoming excoriated from the contact with excrements. The nurse has spoken with the night shift nurse on 2 occasions about the concerns and was told by the night shift nurse that she takes care of the clients and to stay out of her business. What action should the day shift nurse take next? 1. Avoid reporting the night shift nurse to prevent job loss or disciplinary actions. 2. Report the client findings and previous discussions to the charge nurse. 3. Notify the agency attorney of the breach in care being provided. 4. Tell the client's family that they should report the night shift nurse.

The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse? 1. "I wouldn't worry about that; everything will be all right." 2. "You are worried that you may be responsible for your friend's condition?" 3. "How come you were drinking and driving?" 4. "Let's not talk about that right now."

The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first? 1. 12 year old reporting a severe headache 2. 6 month old with respiratory rate of 68/min while sleeping 3. 2 year old with a broken arm who is crying and appears in pain 4. 8 year old with cellulitis of the left leg and an elevated body temperature

The nurse is preparing to educate a client about human papillomavirus (HPV). What information should the nurse include? 1. There is no vaccine to prevent HPV. 2. HPV is the cause of most ovarian cancers. 3. The only way to prevent HPV is refraining from any genital contact with another. 4. HPV is cured by removal of genital warts.

The medical surgical nurse is admitting a client diagnosed with deep vein thrombosis (DVT) of the right leg. The client suddenly begins to report shortness of breath. Which additional early signs/symptoms indicative of a complication would the nurse need to report to the primary healthcare provider immediately? 1. Tachycardia with tachypnea. 2. Restlessness and dizziness. 3. Pain in the lower right leg. 4. A positive Homan's sign.

The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that they didn't do a good job. 4. Provide a between meal supplement to the client.

The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer.

The nurse is assigned a group of clients. For which client would the use of acetaminophen pose a higher risk? 1. 42 year old female who abuses cocaine. 2. 54 year old male who abuses alcohol. 3. 23 year old female who has asthma. 4. 34 year old male with sickle cell anemia.

The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase

The nurse is caring for a client on the post surgical unit. What should the nurse teach the client about short term treatment of post op pain? 1. There are no concerns about addiction from pain medications following surgery. 2. Pain control following surgery rarely results in addiction. 3. The opioid medications typically result in addiction. 4. The primary healthcare provider will not prescribe an addictive medication.

The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. "I must keep my sodium intake steady over time. " 2. "If I miss a dose of lithium, I should make it up with the next dose." 3. "I must check with my primary healthcare provider before changing my diet for weight loss." 4. "I must keep my exercise routine the same or discuss with my primary healthcare provider. "

The nurse is caring for a client that is receiving blood that was started 2 hours ago. The nurse observes that the client has flushed cheeks. What should the nurse do first? 1. Inform the primary healthcare provider. 2. Stop the blood infusion. 3. Obtain a blood sample from the client. 4. Take vital signs.

The nurse is caring for a client with chronic pyelonephritis. Which lab value noted by the nurse indicates a problem? 1. Estimated glomerular filtration rate - 90 mL/min/1.73 m2 2. Serum creatinine - 2.1 mg/dL (186 micro mol/dL) 3. Blood urea nitrogen - 19 mg/dl (6.78 mmol/L) 4. Urine culture isolates Escherichia coli

The nurse is caring for a primipara client at 27 weeks gestation. Which client learning need should the nurse identify as priority at this stage of pregnancy? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

The nurse is discharging a client who had a kidney transplant and the primary healthcare provider has prescribed mycophenolate. Which nursing instruction is priority regarding this medication? 1. Take the medication with food 2. Notify primary healthcare provider at first signs of an infection 3. Nausea, vomiting, and diarrhea are common side effects 4. Use sunscreen when planning to be outdoors

The nurse is irrigating an acid chemical burn on a client's arm. Which would indicate to the nurse that irrigation can be stopped? 1. Client's pain rating has decreased from 6 to 2 on a 0 to 10 pain scale. 2. The pH value of the runoff solution is 7.0. 3. Client reports a burning sensation in the affected arm. 4. Capillary refill is less than 2 seconds in the affected arm.

The nurse is preparing to give a client's prescribed azithromycin dose. How many tablets will the nurse give to the client? Answer with numbers only. Exhibit

The nurse is providing medication teaching to a client starting psyllium. What comment by the client indicates the teaching has been successful? 1. "I should take this medication just before bedtime." 2. "I need to drink large amounts of water with this drug." 3. "I might need to take as many as six doses every day." 4. "I should not eat or drink for two hours after the pill."

The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so independently. What statement by the nurse is appropriate? 1. "Many spouses have been able to learn this procedure." 2. "Which part of this procedure has you most concerned?" 3. "Don't you have any family to help you with this procedure?" 4. "Are you worried about caring for your spouse?"

The nurse is taking care of a client that has been on TPN for 5 days. Upon entering the room, the nurse observes that the TPN has been turned off. What is the nurse's priority action? 1. Flush the IV line 2. Obtain blood glucose level 3. Check written prescription 4. Restart TPN infusion

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

The nurse notices that the primary healthcare provider, who has been looking at a client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible on the computer screen. What is the most appropriate action by the nurse? 1. Log the primary healthcare provider off the facility's health information system. 2. Minimize the screen so that the client information is no longer visible, and then ask the primary healthcare provider if the computer can be logged out. 3. Do not interfer since the primary healthcare provider is responsible for this information. 4. Read the health information that the primary healthcare provider left visible on the computer screen to see if the document was completed.

The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? 1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward." 2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg." 3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand." 4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg, and advance affected leg and the crutches to the step."

The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture? 1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the prescription will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client hourly.

What information would the nurse include when participating in community health training about sexually transmitted infections? 1. Clients are screened for chlamydial infection and/or gonorrhea only if the client is experiencing cervical discharge, dyspareunia, and dysuria. 2. Women with chlamydial infection or gonorrhea are likely to be asymptomatic. 3. In many instances, chlamydia infection and/or gonorrhea will go away without intervention. 4. It is only necessary for females to be treated for chlamydial infections and/or gonorrhea due to the potential damage to a female's reproductive system.

What is indicated when caring for a client admitted with meningitis? 1. The client should be placed in a negative pressure room and health care providers should wear a N95 protective mask when in contact with the client. 2. The client's room door may remain open and health care providers should wear a facemask within 3 to 6 feet of the client. 3. The client should be placed in a private room and no face mask is needed. 4. The only precaution needed is hand hygiene.

What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? 1. Albumin 2. Prealbumin 3. Iron 4. Calcium

Which assessment finding by the nurse is likely to indicate an increased level of stress in a client? 1. Weight at normal level. 2. Daily experience of headaches and other body aches. 3. Use of the problem solving method to handle daily annoyances. 4. Reports of increased creativity in the job situation.

Which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon? 1. Absent bowel sounds. 2. Jackson Pratt drain has 90 mL of blood. 3. Urinary output of 180 mL since return from surgery. 4. Client report of abdominal pain of 8/10.

Which comment made by a new nurse regarding sodium polystyrene sulfonate indicates to the charge nurse that the new nurse understands the effects of this medication? 1. "Sodium is exchanged for potassium in the blood." 2. "Fluids will need to be encouraged after administration." 3. "This medication will increase potassium and decrease sodium." 4. "Sodium polystyrene sulfate is only given as an enema."

Which nursing intervention should the nurse implement when administering a medication through a nasogastric (NG) tube? 1. Place the client in a high-Fowler's position for medication administration. 2. Flush the tubing between administering medications 3. Turn the client onto their left side after medication administration. 4. Mix the medication directly into the tube feeding

Which prescription by the emergency room primary healthcare provider for a client who fell from a ladder should the nurse question? 1. Record intake and output hourly. 2. Prepare the client for lumbar puncture. 3. Perform neurologic checks every 10 minutes. 4. Schedule a brain computed tomography (CT) scan

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? 1. "I want to make my mark on the world." 2. "I am satisfied with my life so far." 3. "I wish I could go back and fix the mistakes I have made." 4. "Life is too short. I have more living to do."

Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.

While preparing to administer intravenous of chemotherapy the nurse accidently pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the nurse's immediate action? 1. Use disposable towels to clean up the liquid. 2. Obtain spill kit specific to this type of solution. 3. Complete an incident report for supervisor. 4. Call housekeeping to help clean up the floor.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2,3,4,5

The nurse is teaching a group of adults how to check skin lesions for signs of melanoma. What should the nurse include? 1. Symmetrical shape 2. Multiple colors with a lesion 3. Odd looking lesion 4. Poorly defined border of lesion 5. Diameter of lesion 6 mm

2,3,4,5

What should the nurse teach the client following a right knee arthroscopy? 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2,3,4,5

A client with a new single chamber pacemaker is receiving instructions prior to discharge. What statement by the client indicates to the nurse the need to review the instructions again? 1. "I can use a cell phone on the side opposite my pacemaker." 2. "I must check and then record my heart rate every day." 3. "It is safe for me to go through the new airport security." 4. "I need monthly pacemaker checks to assess pacer function."

A client diagnosed with a deep venous thrombosis (DVT) has been prescribed warfarin. Which of the client's current medications would the nurse notify the primary healthcare provider related to the prescribed warfarin? 1. Metformin 2. Aspirin 3. Ginkgo 4. Amlodipine 5. Hydrochlorothiazide

2,3

A nurse is participating in a community health fair for middle aged individuals. Which points should the nurse stress for decreasing the risk of stroke? 1. Reduce dietary intake of unsaturated fat. 2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily. 5. Decrease smoking to less than ½ pack a day.

2,3,4

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement? 1. Developing a response plan for every potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Assigning all client care duties to the Nursing Supervisor. Rationale Strategies

2,3,4

Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L)

2,3,4

The client diagnosed with a hemorrhagic stroke has been admitted to the intensive care unit. Which nursing intervention would the nurse initiated to minimize the factors that contribute to increased intracranial cerebral pressure (ICP)? 1. Increase the flexion of the hips 2. Maintain a calming environment 3. Administer stool softener as prescribed 4. Instruct family to not wake the client if sleeping 5. Turn and place pillows behind the client every hour

2,3,4

The nurse is caring for a client following gastric bypass surgery. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? 1. Increase liquids with food. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating.

2,3,4

When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2,3,4

A client reports difficulty sleeping since starting a new job. The nurse's assessment identifies that the client is also working after hours from home. Which teachings are appropriate to promote sleep in this client? 1. Vary bed times to determine time best to promote sleep. 2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

2,3,4,5

A nurse receives a client in the post anesthesia care unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which interventions should the nurse initiate? 1. Elevate foot of bed 30 degrees. 2. Palpate bilateral pedal pulses. 3. Apply ice packs to fracture site. 4. Mark break through bleeding. 5. Assess client's ability to move toes

2,3,4,5

The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.

2,3,4,5

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this assessment? 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes

2,3,4,5

A client from Indonesia is being admitted to the Labor and Delivery unit. Her spouse brought her to the hospital. She is 39 weeks gestation, her contractions are 4 minutes apart, and she experienced spontaneous rupture of the membranes at home. She does not speak English, but a hospital-based interpreter is present. Which questions by the nurse would be appropriate to ask the client when performing the admission assessment? 1. Are there any odd cultural practices that we need to be aware of in caring for you during labor and delivery? 2. In your culture, are fathers generally present for the delivery? 3. Are there any foods that are not permitted or are requested based on your culture or religion? 4. Do you have any personal beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period that you will be observing? 5. Will you be observing any special or culturally accepted way for expression of pain? 6. Are there any special considerations that need to be observed for newborn care?

2,3,4,5,6

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client? 1. Increase speaking volume and tone. 2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

2,3,4,5,6

What assessments would be appropriate for the school nurse to perform related to school safety practices and emergency preparedness? 1. Teach about gun control laws. 2. Observe for gaps or changes in levels of sidewalks. 3. Identify which students have special healthcare needs. 4. Locate all entrances and exits to buildings. 5. Identify threats and hazards in the school and surrounding community. 6. Perform a check of all fire extinguishers.

2,3,4,5,6

The nurse is talking with a group of teenagers who have expressed an interest in getting a tattoo. What information about tattoos should the nurse provide? 1. Apply a moisturizer to the tattooed skin once a day. 2. Carefully consider the tattoo location as weight gain can distort the image. 3. Bloodborne risks of tattooing include Hepatitis and HIV. 4. Tattoo dyes can cause allergic skin reactions. 5. Tattoos can be inexpensively removed with little discomfort. 6. Make sure the tattoo artist removes the needle and tubes from sealed packages.

2,3,4,6

A female client has been ordered a radioactive iodine uptake test (RAIU) to evaluate for Graves' Disease (hyperthyroidism). What priority actions should the nurse complete before the test? 1. Insert IV to administer conscious sedation. 2. Remove all jewelry or metal before the test. 3. Obtain urine specimen to check for pregnancy. 4. Confirm client is NPO for two hours before the test. 5. Verify client stopped anti-thyroid meds for one week.

2,3,5

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2,3,5

The charge nurse is observing a new nurse administer a Mantoux test. The new nurse demonstrates accurate knowledge of the procedure by completing what steps? 1. Administers 0.1 ml of PPD to upper outer arm. 2. Inserts needle under dermis with the bevel up. 3. Uses tuberculin syringe with 27-gauge needle. 4. Wraps site with gauze to prevent leaking. 5. Assesses the injection site after 48 hours.

2,3,5

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? 1. Uses a clean basin and washcloth to clean the ulcer. 2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 4. Warms saline bottle in microwave for 1 minute. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

2,3,5

The staff nurse is caring for a 3-month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? 1. Uses a 15 gtt factor drip chamber when changing the IV tubing. 2. Applies elbow restraints to prevent dislodgement of the IV catheter. 3. Checks the IV site for blood return hourly. 4. Instructs unlicensed assistive personnel (UAP) to count drip rate hourly. 5. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy.

2,3,5

Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? 1. Child dying with leukemia who has been on the hematology/oncology unit for two weeks. 2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.

2,3,5

An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department? 1. Purposeful movement. 2. Sudden emotional outbursts. 3. Client report of blurred vision. 4. Pupils equal, react to light, and accommodation. 5. Bright red blood oozing from the wound. 6. Headache unrelieved by acetaminophen.

2,3,6

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? 1. Smokeless tobacco increases risk for lung cancer. 2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 4. Risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice. 5. Report decreased saliva to primary healthcare provider. 6. Smoking cessation.

2,3,6

A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)

2,4

A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.

A nurse has taught a group of teenage girls about breast self-awareness. Which statements by the teens would indicate to the nurse that teaching was effective? 1. "I should have a clinical breast exam every 5 years starting at the age of 18." 2. "Doing a monthly breast self-exam will help me learn what is normal for me." 3. "It is only important to know my maternal health history." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge." 5. "Self-breast exam should be done a few days before my menstrual cycle begins."

2,4

Which client is legally able to sign a consent for surgery? 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.

2,4

Which tasks would be appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)? 1. Ask the client diagnosed with dementia memory-testing questions. 2. Monitor the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who as a fever. 5. Assess oxygen saturation on a client experiencing angina.

2,4

A client arrives to the after hours clinic with reports of palpitations and skipping heart beats. The nurse notes the client to be alert and oriented with a BP of 124/76, HR irregular at 95 beats per minute, respirations at 18 breaths per minute, and is afebrile. Cardiac monitoring is initiated. Based on this data, what questions should the nurse ask the client? Exhibit 1. "Have you been prescribed a tricyclic antidepressant?" 2. "Have you been experiencing more stress than usual in your life?" 3. "Does this generally begin when you are having a bowel movement?" 4. "How many cups of coffee do you drink each day?" 5. "What over the counter medications do you take?" 6. "Have you been running a fever?"

2,4,5

An unresponsive 13 year old is brought into the emergency department. Based on the nursing assessment and current lab data, which interventions would be appropriate for the nurse to initiate? Exhibit 1. Administer kayexelate 2. Initiate IV of NS 100 ml with Regular insulin 100 units at 10 mL/hr 3. Start oxygen at 2 liters per nasal cannula 4. Start a second IV for fluid resuscitation. 5. Insert indwelling urinary catheter

2,4,5

Which assessment finding by the nurse is likely to be the result of long-term corticosteroid use in a client? 1. Occasional nausea that occurs after eating the evening meal. 2. A wound that is slow to heal. 3. Weight loss of 15 pounds (6.8 kg) over a 6 week period. 4. The appearance of acne on the forehead and cheeks. 5. Vertebral compression fracture.

2,4,5

Which nursing actions should the nurse initiate for a client with signs of increased intracranial pressure (ICP)? 1. Encourage coughing and deep-breathing. 2. Administer corticosteroids. 3. Position client in the prone position. 4. Determine ability to swallow prior to administering po fluids. 5. Maintain head in neutral alignment.

2,4,5

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.

2,4,6

A client has been admitted with a stroke on the right side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? 1. Right sided hemiplegia 2. Impaired judgment 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech

2,5

A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5. Send list of allergies to dietary department.

2,5

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

2,5

The nurse is preparing to discharge a client home from the hospital. Which statement made by the client indicates to the nurse that instructions about antibiotic administration have been successful? 1. "I will take the antibiotic until I feel better but save some to take in case the infection returns." 2. "I should follow the instructions on the label." 3. "I need to double the dose for two days so I will get better." 4. "I should double the dose the next time the antibiotic is due after missing a dose." 5. "I will finish all of my antibiotic medication."

2,5

The nurse notices that a client's bedside privacy curtain has been left partially open during the client's bath. Which are appropriate actions for the nurse to take in order to ensure the client's right to privacy? 1. Inform the client that the curtain was left partially open. 2. Close the privacy curtain to protect the client's right to privacy. 3. Since the client did not notice the open privacy curtain no action is necessary. 4. Only a few visitors are on the unit at this time so no action is necessary. 5. Instruct the nurse giving the client's bath about the open curtain and need for privacy.

2,5

What task can the nurse assign to an unlicensed assistive personnel (UAP) while caring for a client diagnosed with a stroke? 1. Check the client's gag reflex. 2. Assist with feeding the client. 3. Monitor the client's headache pain level. 4. Encourage client to expression frustrations. 5. Maintain the head of the bed at 25 - 30 degrees.

2,5

A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? 1. Assess the wounds for drainage. 2. Give ice chips sparingly. 3. Maintain the patency of the NG tube. 4. Monitor for the return of peristalsis.

The primary healthcare provider has prescribed KCL 40 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

A 17 year old adolescent and girlfriend are being treated in the emergency room for moderate injuries following a motorcycle accident. The adolescent is unconscious and will need surgery but family cannot be located to give consent. What does the nurse know is true about informed consent? 1. Informed consent can be provided by the girlfriend. 2. Consent is not necessary in this particular situation. 3. Surgery must be delayed until the family is located. 4. Surgery cannot be done while client is unconscious.

A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign a nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? 1. Lie on left side and take slow, deep breaths. 2. Call an ambulance and go to emergency room. 3. Come to the clinic for assessment and evaluation. 4. Go directly to the hospital emergency room.

A client diagnosed with an embolic stroke has been admitted to the medical unit. Which nursing assessment would the nurse include to identify an early sign of increased intracranial pressure (ICP)? 1. Bradypnea 2. Bradycardia 3. Irregular respirations 4. Elevated systolic pressure

A client diagnosed with an embolic stroke is presenting with homonymous hemianopsia. Which nursing intervention would the nurse implement for homonymous hemianopsia. 1. Move to the client on their nonintact visual field side 2. Instruct the client to wear their eye glasses less often 3. Position items necessary for activities of daily living in the client's visual field 4. Teach the client to practice moving their eyes up and down and side to side

A client diagnosed with glaucoma is being instructed on self-instillation of eye drops. What statement by the client would indicate to the nurse that teaching was successful? 1. "I should look into the mirror to be sure I am getting the drops in." 2. "I will put all drops in my eyes and then close eyes for 5 minutes." 3. "I have to be sure not to touch the dropper to any part of my eye." 4. "I have to pull down the upper lid when putting the eye drops in."

A client diagnosed with human immunodeficiency virus (HIV) is to be sent home today. The nurse has initiated discharge instructions on the proper handling of blood and body fluid at home. The nurse knows the teaching is successful when the client makes what statement? 1. "As long as it's my home, I can use normal cleaning methods." 2. "I must scrub with hot, soapy water and allow it to air dry." 3. "I should clean area with a 10% mixture of bleach and water." 4. "I must sterilize with isopropyl alcohol and rinse with ammonia."

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries

A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider? 1. Early decelerations 2. Fetal heart rate (FHR) 160/min 3. Blood pressure 90/62 4. Temperature of 99.6° F (37.5° C).

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

A client is sedated. His wife asks the nurse about her husband's test results. The client does not have a healthcare proxy or durable power of attorney executed at this time. How should the nurse respond in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations regarding the confidentiality of the sedated client's health information? 1. I can't give you those results. You should ask his primary healthcare provider the next time that he comes in to examine your husband. 2. Those test results are confidential, but since you are his wife I can give them to you. Let me look them up in the computer system. 3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. 4. Your husband is only lightly sedated. I can wake him up and ask him if it is all right to release these test results to you.

A client is seen in the clinic for recurrent, unexplained, vague stomach pain over the past 5 years. Esophagogastroduodenoscopy (EGD), colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the pain. The client tells the nurse, "the pain is so bad sometimes that I can't function!" What disorder is this client likely experiencing? 1. Conversion disorder 2. Pseudocyesis 3. Somatization disorder 4. Dysmorphic disorder

A client is to undergo an endoscopy in the client's room. The gastroenterologist gives a verbal prescription to the general floor nurse to prepare and administer propofol 10 mL slow IVP until sedation is achieved. What action should the nurse take? 1. Administer the propofol as prescribed. 2. Draw up the propofol and give it to the gastroenterologist to administer. 3. Inform the gastroenterologist that giving propofol is outside the nurse's scope of practice. 4. Request the gastrointerologist write the prescription.

A client is transported to the emergency department by the police following a sexual assault. What is the nurse's priority intervention? 1. Instruct the client to remove all of her clothes so they can be bagged as evidence. 2. Ask the client to describe what happened . 3. Tell the client she is safe here. 4. Perform a rape kit in order to preserve the evidence

A client on the med-surg unit is being treated for dehydration and pneumonia. The UAP has entered the room to complete AM care, but the client refuses, reporting feeling too tired from a "poor night's sleep". The UAP reports the refusal to the nurse. What statement by the nurse provides the best explanation to the UAP? 1. "Explain to the client that we are short staffed, so AM care needs done at this time." 2. "Don't worry about it; just tell the next shift they will need to do this client care." 3. "Let's look over your shift assignments to see if we can rearrange some other tasks." 4. "It is crucial for this client to be able to rest, so clean sheets can wait till tomorrow."

A client receiving palliative care is reporting constipation. What intervention should the palliative care nurse provide first? 1. Increase foods high in fiber. 2. Administer an enema 3. Increase fluid intake 4. Administer docusate sodium

A client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm. 3. Have the staff RN recheck the BP. 4. Ask the LPN to recheck the client's BP.

A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.

A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the nurse that discharge teaching has been effective? 1. I will need to eat a low fat diet since I no longer have a gallbladder. 2. I can expect drainage from the incisions for a few days. 3. I may have some mild pain from the procedure. 4. I should plan to limit my activities and not return to work for several weeks.

A client with a diagnosis of embolic stroke is admitted to the medical unit. After 2 hours on the unit the client presents with agitation. Which nursing intervention would the nurse initially implement? 1. Assess the client for any seizure activity 2. Assess the client with the Glasgow Coma Scale 3. Place the client's neck in the midline position 4. Adjust the head elevation to 15 degrees

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.

A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."

A client with recurrent angina and hypertension has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? Exhibit 1. 2 gm sodium diet 2. Metoprolol 25 mg PO once daily 3. Potassium 10 meq PO once daily 4. Diltiazem 120 mg PO once daily

A client with the diagnosis of mild anxiety asks the nurse why the primary healthcare provider switched medications from lorazepam to buspirone. What should the nurse tell the client? 1. "Lorazepam takes longer to start working than buspirone so the primary healthcare provider decided to switch medications." 2. "Buspirone can be stopped quickly if neccessary." 3. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation." 4. "You need to ask your primary healthcare provider why the medication was changed from lorazepam to buspirone."

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

A hospitalized American Indian elder is actively dying and is surrounded by a large group of family members. The client's spiritual beliefs include burning a tiny amount of incense while chanting softly. The roommate summons the nurse, complaining about the noise and the odor despite the fact the curtain is drawn between the beds. What is the most appropriate action by the nurse? 1. Tell the client's family the noise and odor bothers the roommate. 2. Move the elder to a private room so family can continue ceremony. 3. Offer to move the roommate to another room in a quieter area. 4. Explain the client is dying and the family will soon be leaving.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The nurse considers various ideas submitted by team members. What proposal would the nurse determine to best meet the needs of families and clients in long term care? 1. Plan all care to be completed in early morning to allow afternoon for visitation. 2. Schedule visiting times in two-hour increments so clients are not overwhelmed. 3. Encourage clients and families to develop mutually appropriate visitation times. 4. Allow families unlimited visitation around the clock to meet their schedules.

A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowlers position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.4, PaCO2 - 40, HCO3 - 24 2. pH - 7.48, PaCO2 - 29, HCO3 - 22 3. pH - 7.44, PaCO2 - 30, HCO3 - 18 4. pH - 7.46, PaCO2 - 32, HCO3 - 20

A nurse has received report on a client to be admitted from the surgical suite following an unexpected amputation of the right arm because of a tractor accident. Which action by the nurse would best help the client upon arrival to the unit? 1. Notify hospital social services about adaptive equipment needs. 2. Prepare to change the dressing so the client can see the stump. 3. Ask client's family and hospital chaplain to be present in room. 4. Advise dietary that client will need food precut in small pieces.

A nurse is caring for a client admitted with a diagnosis of depression and suicidal thoughts. The client states, "My husband doesn't love me anymore, and so life is just not the same." What would be the most appropriate response by the nurse? 1. "Even though your husband does not love you, life can still be very meaningful." 2. "Many couples go through difficult times in their marriage, but you should not assume that he does not love you anymore." 3. "Tell me what has led you to believe that your husband doesn't love you anymore." 4. "You really need to try not to let your husband make you depressed and feel that life is not worth living."

A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction(MI)? 1. I became dizzy when I stood up. 2. I was nauseated and began vomiting. 3. The pain started in my chest and stopped after I sat down. 4. The pain was not relieved after taking 3 nitroglycerine tablets.

A nurse is receiving morning report on the cardiovascular unit. What client should be the nurse's priority assessment? 1. A client with ejection fraction of 20% and dyspnea at rest. 2. A client with a chest tube to suction and sub-q emphysema. 3. A client two days past abdominal aortic aneurysm repair with decreased pedal pulses. 4. A client coronary artery bypass graft three days ago with WBC 17,000 mm3.

A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Based on the information provided in report, which client condition should be the nurse's priority? 1. Potassium level of 3.4 mEq/L (3.4 mmol/L) in a child with vomiting and diarrhea. 2. Platelet count of 95,000/mm3 in a child with a nose bleed. 3. Absolute neutrophil count of 400/mm3 in a child with fever. 4. Hemoglobin level of 9 g/dL (90 g/L) in a child with reports of fatigue.

A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.

A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 1. Client needs to be isolated until delivery. 2. Client is immune to rubella currently. 3. Client should be given rubella vaccine after delivery. 4. Client has never been exposed to rubella.

A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."

A toddler with a malfunctioning ventriculoperitoneal (VP) shunt has returned from surgery following new shunt placement. Which post-op assessment finding should the nurse report to the primary healthcare provider immediately? 1. Blood pressure of 90/45 with pulse of 100 2. Urinary output of 30 mL over two hours 3. Sleeping soundly and difficult to arouse 4. Respirations deep and shallow at 20/min

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

An adult client's parent, who is a physician, comes to the nurse's station and requests the client's chart. The physician is not the client's primary healthcare provider but is employed by the hospital. What action should the nurse take? 1. Provide the physician with the chart. 2. Ask the primary healthcare provider to consult the physician in the client's care. 3. Explain to the physician why access to the chart cannot be provided. 4. Obtain verbal permission from the client for the physician to view the chart.

An elderly client diagnosed with Alzheimer's disease has become combative, restless and wanders at night. The nurse contacts the primary healthcare provider for medication to help the client rest. The nurse knows the best choice for this client is what medication? 1. Chlorpromazine 2. Hydroxyzine 3. Haloperidol 4. Diazepam

During a health fair, a client asks the nurse about the methods used to detect prostate cancer. What should the nurse tell the client about the detection process? 1. Abdominal x-rays to detect the presence of lesions and masses. 2. A serum calcium test to detect elevated levels, which may indicate bone metastasis. 3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 4. A magnetic resonance image (MRI) study to detect tumors and other abnormal growths.

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? 1. Elevate the head of the client's bed. 2. Start giving the client 8 ounces of oral fluid per hour. 3. Check circulation and take the vital signs of the client. 4. Continue monitoring, because this is an expected finding.

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.

The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the post-partum unit.

The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take? 1. Cover the sterile field with a sterile drape until the surgery is about to begin. 2. Close and tape the OR doors so that no one may enter. 3. Monitor the sterile field while awaiting the surgeon. 4. Tear down the sterile field until the surgeon arrives in the OR.

The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"

The community health nurse plans to educate a client diagnosed with tuberculosis (TB) how to avoid spreading the disease to others. What should the nurse include when educating this client? 1. Wear a N95 respirator when around family at home. 2. Have adult family members get the TB vaccine. 3. Complete TB medication regimen. 4. Live at a sanatorium until cured of TB.

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

The homecare nurse is visiting a client who recently had a miscarriage at 22 weeks. When is the most appropriate time for the nurse to discuss the topic of another pregnancy? 1. The topic should wait until the nurse builds rapport with the client. 2. Another pregnancy should not be discussed for at least six months. 3. Wait until the client initiates the topic of future pregnancies. 4. Discussion should begin immediately upon the first home visit.

The labor and delivery charge nurse is making staff assignments, including assignments to a new nurse. What client is most appropriate for the new nurse? 1. A gravida 3 para 2 in active phase of stage one, expecting twins. 2. A gravida 2 para 0 at 41 weeks gestation, awaiting induction. 3. A primigravida in active phase of stage one, waiting for epidural. 4. A 12-hour post Cesarean section needing assistance to ambulate.

The nurse has initiated instruction for an 11 year old child newly diagnosed with diabetes mellitus. The child indicates anxiety about the need for daily insulin injections. What nursing action would best address this issue? 1. Tell the child it only hurts for a moment. 2. Have the parents administer the shots. 3. Show the child how to give self injections. 4. Provide toy syringe for the client to play with.

The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? 1. Increased episodes of fussy crying. 2. A hacking, non-productive cough. 3. Oral temperature of 100.9°F (38.3°C). 4. Chest tube draining 30 mL per shift.

The nurse is caring for a client who is receiving weekly infusions of Factor VIII for Hemophilia. What assessment finding by the nurse related to the client's skin is indicative of a therapeutic response? 1. An absence of jaundice 2. The presence of petechiae 3. A reduction of bruising 4. A capillary refill time of < 3 seconds

The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client? 1. Ask the client to go to the group session with you. 2. Remind the client to interact with the nurse today. 3. Sit with the client and make no demands. 4. Allow the client to decide when to talk with the nurse.

The nurse is caring for an oncology client with a WBC-5.5 x 103 /mm3, Hgb-12g/dL, PLT-90 x 103 /mm3. Which measure should be instituted? 1. Protective isolation 2. Oxygen therapy 3. Bleeding precautions 4. Strict intake and output

The nurse is completing the admission assessment on an elderly client newly arrived on the orthopedic unit. When asked about past medical history, the client indicates "some joint problems", but cannot provide further information. What further statement by the client suggests to the nurse the disease is likely rheumatoid arthritis? 1. "My joints are really stiff and hurt every morning." 2. "I have pain in my knees if I've been sitting a while." 3. "I am better for a few months, but then get bad again." 4. "My fingers hurt and the knuckles seem to get bigger."

The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

The nurse is explaining HIPAA regulations to a new client admitted for the first time. What statement by the nurse is most accurate regarding client's personal health information? 1. Cannot be released to other organizations without client consent. 2. May never be used for research purposes or disease tracking. 3. Permission is implied if client has family in room during exam. 4. Will not be publically released without direct client consent.

The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.

The nurse is reinforcing proper use of the walker with partial weight-bearing to a client with a total hip arthroplasty. Which action would indicate to the nurse that the client is using the walker correctly? 1. Leaning over the walker. 2. Using a walker with 4 wheels. 3. Elbows positioned at 30 degrees. 4. Lifts the walker when climbing steps.

The nurse is teaching a client diagnosed with asthma about using a peak expiratory flow meter. The nurse asks the client what action should be taken if the reading is 65% of the client's personal best value. What statement by the client indicates to the nurse that education was successful? 1. "This is a good reading for me, so I can go about my usual activities." 2. "I will administer my long-term inhaler medication." 3. "My as needed inhaler medication needs to be administered." 4. "I need to immediately call 911."

The nurse is teaching a pregnant teenage client about resources available through the health department. The client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.

The nurse is working with the interdisciplinary team in developing a plan of care focused on weight gain for an anorexic client. What intervention would be ineffective for reaching that outcome? 1. Refrain from being critical of client during meals. 2. Permit client to make own food selections on menu. 3. Reward the client with private time for a meal completely eaten. 4. Provide positive reinforcement for each pound gained.

The nurse manager is making rounds in a long-term care facility and discovers an unfamiliar client standing in the hallway in a puddle of liquid. What is the nurse manager's priority action? 1. Ask client to state name and room number. 2. Find dry clothes and clean client completely. 3. Wipe up puddle of liquid and call housekeeping. 4. Contact unit charge nurse to identify the client.

The nurse manager is presenting a seminar on HIPAA regulations to a group of newly hired graduates. When discussing the most common cause of violating client privacy, the nurse knows teaching was successful when the graduates select what situation? 1. Failure to cover client fully during a bed bath. 2. Leaving chart open in full view when at the desk. 3. Discussing client with staff not providing direct care. 4. Healthcare provider not pulling curtain to talk to client.

The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. In order to reorganize staffing, the nurse manager should initiate which action first? 1. Announce the new changes at the monthly staff meeting. 2. Ask for any staff objections to rearranging work hours. 3. Invite staff to contribute ideas on scheduling changes. 4. Explain administration is demanding a decreased overtime.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

The nurse working in a pediatrician's office is teaching a couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.

The parents of a toddler are worried about their child's poor meat intake resulting in a low iron level. What would be the best recommendation for the nurse to make? 1. Offer split pea soup once a week with a glass of milk. 2. Provide spinach twice a week. 3. Cook with an iron skillet. 4. Encourage fresh fruit intake.

Two nurses are checking a unit of packed red blood cells (PRBCs) for client compatibility prior to infusion. What action should the primary nurse take after completing this process? Exhibit 1. Initiate the PRBCs transfusion at 25 mL/hour for the first 15 minutes. 2. Ask blood bank personnel to type and cross match for PRBCs sent to unit. 3. Send unit of PRBCs back to the blood bank. 4. Notify the primary healthcare provider.

What action by a new nurse who is drawing up a medication from an ampule would require intervention by the supervising nurse? 1. Taps the top of the ampule to remove medication trapped in the top of the ampule. 2. Snaps the neck of ampule away from the body when breaking the top off. 3. Withdraws medication using a 22 gauge needle. 4. Inverts ampule, places needle tip in liquid, and withdraws all of the medication.

What information should be included when a nurse is teaching a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? 1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids.

When preparing to administer the client a dose of intravenous (IV) antibiotics, the nurse notes that the IV pump cord is frayed with wiring visible. What priority action should the nurse take? 1. Notify maintenance to come and check the pump immediately. 2. Continue to use the IV pump and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance.

A client is being discharged with halo traction. What should the nurse teach about home care of this traction? 1. Showering is permitted. 2. Apply baby powder under the halo vest to prevent irritation. 3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique. 5. Driving is allowed after discharge.

3,4

Which action should the nurse recommend to parents so that their home will be safer for a toddler? 1. Place the child in the center of an adult-sized bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised.

Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).

Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)

Which statement by a client diagnosed with infectious mononucleosis indicates to the nurse that education has been successful? 1. "I should let my primary healthcare provider know if I start having pain in the side of my stomach" 2. "I can return to my normal activities in 5 days." 3. "I will not let others drink from my glass." 4. "My immediate family needs to get vaccinated against mononucleosis."

Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."

An unlicensed assistive personnel (UAP) reports to the charge nurse that a postoperative client's 8AM blood pressure is 200/104 and the oxygen saturation reading is 86%. What actions would be appropriate for the charge nurse to delegate? 1. Tell the LPN to assess for shortness of breath and evidence of tissue prefusion. 2. Have the LPN reinforce the use of relaxation techniques. 3. Ask the LPN to draw arterial blood gas levels. 4. Instruct the RN to administer the prescribed dose of labetalol hydrochloride IV. 5. Instruct the UAP to call the primary healthcare provider and notify of change in client's condition.

3,4

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.

3,4

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? 1. Pertussis 2. Rotovirus 3. Tuberculosis 4. Varicella

The nurse is providing care for an elderly client who has a percutaneous endoscopic gastrostomy (PEG) feeding tube and is receiving continuous feeding. Which interventions should the nurse include when providing care? 1. Add medications to enteral feeding formula. 2. Change dressing around insertion site weekly. 3. Flush feeding tube with 30 mL warm tap water every 4 hours. 4. Maintain head of bed at 30 degree elevation. 5. Monitor for hypoglycemia.

3,4

The nurse is reinforcing the dietary discharge instruction for a client prescribed warfarin. Which food choices should be avoided on the warfarin dietary instruction plan? 1. Corn 2. Carrot 3. Spinach 4. Broccoli 5. Watermelon

3,4

The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.

3,4

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

3,4

A client is being discharged with halo traction. What should the nurse teach the client and family about home management of this traction? 1. Showering is permitted once a week with assistance. 2. Apply baby lotion under the halo vest to prevent irritation. 3. Sleep in whatever position is found to be most comfortable. 4. Never pull on any part of the halo traction. 5. Clean around pins at least once daily with a new q-tip for each pin site.

3,4,5

A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation? 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling.

3,4,5

The nurse is preparing to administer a dose of sacubitril/valsartan 24/26 mg by mouth. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the sacubitril/valsartan? Exhibit 1. Bilateral crackles noted to posterior lung fields. 2. Potassium- 4.8 mEq/L (4.8 mmol/L). 3. Currently taking trandolapril 2 mg by mouth daily. 4. Concomitant use or use within 36 hours of ACE inhibitors. 5. ACE inhibitors increase risk of angioedema. 6. Decreased Hematocrit.

3,4,5

What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)? 1. Monitor Central venous pressure (CVP) 2. Administer diuretic 3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities

3,4,5

What measures should the school nurse implement for a child diagnosed with peanut allergies? 1. Keep a lidocaine auto-injector readily available. 2. Obtain assessment data about visual acuity, and health conditions that might affect food allergy management. 3. Maintain contact information for parents and primary healthcare provider. 4. Review history of known food allergens and the severity of previous reactions. 5. Train designated personnel to administer prescribed medication in an anaphylaxis emergency.

3,4,5

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? 1. Assess a client's ability to swallow. 2. Develop a plan of care for hygiene needs. 3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. 6. Teach the family about the need to prevent pressure ulcers.

3,4,5

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Exhibit 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per nonrebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL.

3,5

A nurse is planning to teach a group of adult males in their 40's about health care promotion recommendations. Which recommendations should the nurse include? 1. Do bi-annual skin self-exam to check for new moles or changes in moles. 2. Comprehensive eye exam every 5 years starting at age 45. 3. Limit alcohol intake to no more than two drinks per day. 4. Yearly physical exam from a health care provider. 5. Get at least 30 minutes of moderate physical exercise on most days of the week.

3,5

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3,5

The RN, LPN, and unlicensed assistive personnel (UAP) are providing care for clients on the nursing unit. Which tasks could be completed only by the RN? 1. Administration of routine medications. 2. Dressing changes. 3. Assessment of newly admitted clients. 4. Calling the primary healthcare provider about lab results. 5. Teaching the diabetic client foot care.

3,5

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the unlicensed assistive personnel (UAP)? 1. Obtain a urine sample from an infant. 2. Empty a nasogastric (NG) canister for client with ileus. 3. Feed a child with bilateral burns of hands. 4. Change an ostomy appliance on child with stoma. 5. Ambulate an adolescent two days post appendectomy.

3,5

A client is being cared for on the orthopedic unit following a football game injury which resulted in a fracture of the left tibia and fibula. An open reduction of the fracture has been performed and a leg cast was applied. The client is receiving Morphine via a Patient Controlled Analgesia (PCA) pump at 2 mg/hr. The client begins reporting an increase in the pain level (9/10) that is not being relieved by the current Morphine dosing, and is experiencing a sensation that "pins are sticking" in the left foot. What action by the nurse is needed? 1. Increase the PCA dosing of Morphine. 2. Elevate the foot of the bed. 3. Perform neurovascular checks. 4. Apply ice around sides of cast. 5. Prepare for possible bivalving of the cast. 6. Notify primary healthcare provider.

3,5,6

A child who fractured the ulna and radius following a fall is experiencing itching under the cast. What would be an appropriate nursing intervention to help alleviate the itching? 1. Apply a small amount of hydrocortisone cream with a cotton tip applicator. 2. Use a soft, sterile, cotton tip applicator to gently rub area under the cast. 3. Apply warm, dry heat to the outside of the cast with a lightweight heating pad. 4. Circulate air under the cast utilizing a blow dryer on the cool setting.

A client admitted to the mental health unit for a suicidal attempt has been progressing slowly in treatment. Suddenly, the client has voiced a much more positive outlook and tells the nurse "I am going to be fine now." What is significant about this situation? 1. The nurse should expect that the treatment has been effective. 2. The client is developing a more positive outlook. 3. The client sees hope for the future. 4. The client may have decided to kill himself.

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.

A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? 1. Ambulate client around room every 2 hours. 2. Assess Homans' sign every 8 hours. 3. Place sequential compression device on both legs. 4. Apply intermittent warm, moist soaks to affected area.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which instruction is most important for this client? 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

A client is being cared for in the intensive care unit following a traumatic amputation of the left lower arm. As the nurse enters the room for a routine check, the client begins to cry and states "This is so overwhelming." What statement by the nurse would be most appropriate at this time? 1. "You have been through a lot, but look on the bright side; you are doing better now." 2. "Try to be optimistic. You are going to be fitted for a prosthesis once you are healed." 3. "I understand that you are upset, but crying is not going to help your situation." 4. "This must be very difficult for you. What seems to be the hardest part for you now?"

A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental". The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? 1. The right to refuse photos of the wound. 2. The right to refuse a blood alcohol test. 3. The right to refuse a tetanus injection. 4. The right to refuse police notification.

A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? 1. "I must keep both eyes covered till my check-up." 2. "I should only have pain for about two days." 3. "I will no longer have to wear reading glasses." 4. "My vision will be blurry for a couple weeks."

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate? 1. Your children are correct. The open heart surgery is the best thing for your health. 2. You feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery. 3. I can contact your primary healthcare provider so that you can discuss your concerns regarding open heart surgery. 4. You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns.

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN? 1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours.

A client who has a long leg cast is reporting unrelieved pain. What should the nurse do first? 1. Apply a cool compress. 2. Elevate and reposition the leg. 3. Assess for breakthrough bleeding on the cast. 4. Monitor extremity for paresthesia.

A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity should be planned for this client for the period following the evening meal? 1. Encourage the client to watch TV with the other clients on the unit. 2. Engage the client in a game of ping pong. 3. Suggest that the client play monopoly with other clients. 4. Provide soft lighting in the client's room for reading.

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

A female client who identifies herself as a Muslim arrives at the outpatient clinic with abdominal pain. Which initial question should the nurse ask to obtain cultural information? 1. "Do you need a family member in the room with you?" 2. "What can you tell me about your culture?" 3. "Have I positioned you so that you are facing toward Mecca?" 4. "Are you comfortable being cared for by a male primary healthcare provider?"

A homecare client with terminal cancer is taking morphine sulfate and reports the current dose is no longer relieving the pain. What would the nurse tell the client about the increased discomfort? 1. The pain medication will need to be taken consistently around the clock. 2. A different pain medication will need to be prescribed since addiction has occurred. 3. As the cancer spreads, the pain medication will no longer help. 4. A tolerance to the current dose has occurred, so the dose will need to be increased.

A nurse is caring for a client who has been prescribed sucralfate. Which client education intervention would the nurse include for the client prescribed sucralfate? 1. Take medication 1 hour after meals. 2. Crush tablets prior to taking medication. 3. Consume 1000 mL of fluid every 24 hours. 4. Avoid antacids 1 hour before and after this medication.

A nurse is receiving report on a telemetry unit. What client is the nurse's priority assessment? 1. Client with diabetes and with newly debrided leg wound draining serous fluid. 2. Client with asthma and with shortness of breath and high-pitched wheezes. 3. Client with right plural effusion and absent breath sounds on right. 4. Client with history of congestive heart failure coughing up pink frothy sputum.

A paralyzed adolescent admitted for decubiti debridement has brought multiple personal electronics, including a laptop, cell phone and video game unit. The nurse notes the family has used extension cords to provide enough electrical outlets. What action by the nurse is most appropriate? 1. Inform family some of the electronics must be taken home. 2. Explain that extension cords are not permitted in a hospital. 3. Notify maintenance to install more outlets in the client room. 4. Ask client to have staff switch equipment in outlets as needed.

A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke". What should the nurse do immediately? 1. Confirm that fluid is amniotic fluid with a pH test strip 2. Obtain maternal vital signs 3. Observe amniotic fluid color 4. Check fetal heart rate (FHR) pattern

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help the client cope at this time? 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk."

A young adult is brought into the ER after experiencing hallucinations at a beach party. The paramedics report a large quantity of beer cans and empty plastic baggies around the bonfire. During the nursing assessment, the client jumps up screaming, "Get those snakes away from me." What initial action by the nurse would most likely result in a positive outcome for client and staff? 1. Summon security to the ER to physically restrain the client. 2. Ask paramedics to restrain client to inject haloperidol. 3. Call nursing supervisor and request 4-point-leather restraints. 4. Close the door and quietly reorient client to current location.

An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first? 1. Decrease rate of IV fluids. 2. Neurovascular checks of affected leg. 3. Elevate the head of the bed. 4. Call the active response team.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

An elderly client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the low dose regimen with regular insulin every 6 hours. The 2400 hours glucose level is 252 mg/dL. How much regular insulin should the nurse give the client at this time? Answer using numbers only. Exhibit

An unlicensed assistive personnel (UAP) is asked to transfer a client with left hemiplegia from the bed to a wheelchair. The nurse tells the UAP the safest approach for this transfer is what method? 1. Lift client from edge of bed, supporting under arms and pivot to chair. 2. Utilize a slide board to transfer client from bed to the wheelchair. 3. Apply an ambulation belt around client's waist and pull into the chair. 4. Use a mechanical lift to move client from the bed into the wheelchair.

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? 1. "I must include a lot of fluid in my daily routine." 2. "I need to take my antibiotics at the same time daily." 3. "Rest and mild exercise are important for my recovery." 4. "Decreasing fiber in my diet can help prevent recurrences."

During client care rounds, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary healthcare provider writes the prescription. Which statement best describes this process? 1. Collaboration with the ancillary care providers. 2. Collaboration between the primary healthcare provider and the dietician. 3. Collaboration with the risk management team. 4. Collaboration among members of the multi-disciplinary team.

During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client.

Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action? 1. Position client on the right side. 2. Call the primary healthcare provider. 3. Lower the head of the bed immediately. 4. Hyperventilate client with a bag valve mask.

How would a case manager best describe a clinical pathway to nursing students? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider prescriptions for client care, which expedite the prescription process and can be customized to individual clients. 4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.

The nurse is preparing to give a client's prescribed ceftazidime dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only. Exhibit

6.6

The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit on the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application.

The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? 1. "This medication will be given to me as an IM injection immediately after my muscles are tired." 2. "This test will determine if I have multiple sclerosis." 3. "The test is positive if my muscles do not get stronger after injection with this medication." 4. "I will be asked to perform a repetitive movement to test my muscles."

The hospice nurse has been assigned a new client who is being cared for at home by family members. Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time? 1. Providing care for the client, allowing the family to rest. 2. Providing education regarding the symptoms the client will likely experience. 3. Allowing the family to express their feelings and actively listening. 4. Communicating the client's impending death to the family while they are together.

The morning assessment of a client admitted with congestive heart failure reveals a weight gain of 2.5 pounds (1.14 kg) since the previous day, crackles in lung fields bilaterally, dyspnea, sacral edema, and bounding peripheral pulses. Which prescription by the healthcare provider should be the nurse's priority? 1. Maintain accurate intake and output. 2. Restrict sodium in the diet. 3. Limit fluids to 1500 mL per day. 4. Administer furosemide 40 mg IV push.

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.

The nurse asks if the client has an advance directive. The client responds by saying, "I have heard of advance directives, but I do not have one. What is an advance directive?" Which response by the nurse is appropriate? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated.

The nurse is caring for a client on the oncology unit. The client asks, "Why do I need this LifePort to receive my chemotherapy?" What evidence should the nurse consider when answering? 1. IV infusions can be more rapidly administered via an implantable IV port 2. Implantable IV ports are kept sterile and therefore do not become infected 3. Chemotherapeutic agents are more readily absorbed from implantable IV ports 4. Implantable ports are beneficial when long-term and/or multiple IV therapy is indicated.

The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, "I am just not feeling well. My medicine is not working." Which reply by the nurse indicates adequate understanding of treatment? 1. "I agree, your medication is not working." 2. "Your treatment may have to be changed." 3. "Most SSRIs take about 5 days to work." 4. "You should reach the desired effect in 1-3 weeks."

The nurse is caring for a client with tuberculosis receiving isoniazid therapy. Because of the possible peripheral neuropathy that can occur, which supplementary nutritional agents would the nurse expect to administer? 1. Cyanocobalamin 2. Vitamin D 3. Ascorbic acid 4. Pyridoxine

The nurse is checking a two year old's developmental status. What finding would be of concern to the nurse? 1. Unable to use "me" and "you" correctly. 2. Has trouble focusing on one activity for more than 5 minutes. 3. Does not follow a 3-part command. 4. Does not know what to do with a spoon.

The nurse is instructing expectant first-time mothers about the process of rooming-in while at the hospital. After discussing security protocols, one client asks the nurse what to do if no staff is available when toileting or showering assistance is needed. The nurse knows teaching was successful when another client responds with what statement? 1. "Only hand the baby to individuals wearing proper hospital I.D." 2. "Ask family member to watch infant while you're in the bathroom." 3. "Showering is not necessary since discharge is within 24 hours." 4. "Push baby in bassinet with you into bathroom if no one available."

The nurse is providing care to an elderly widow recovering from surgical repair of a fractured hip. The client had been teaching school, but now fears the school district may use this injury to force retirement. The client indicates anxiety about not working and being bored. What statement by the nurse would be most therapeutic at this time? 1. "You should enjoy sleeping in and much quieter days." 2. "Don't you have friends or hobbies you would enjoy?" 3. "Maybe you could just look for another job to do." 4. "What part of being retired concerns you most?"

The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward.

The nurse is reviewing a safety contract with a client who is suicidal. However, the client declines to sign the safety contract at this time. What action must the nurse take? 1. Check that all windows are locked and the doors secured. 2. Secure the room by removing potentially harmful objects. 3. Place client in a chair at nursing station until contract is signed. 4. Assign a staff member to stay with client, even in the bathroom.

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse is responsible for the assessment of all vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

The nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

The postanesthesia care unit has received several postoperative clients. While encouraging the clients to cough and deep breathe, the nurse realizes that coughing poses the greatest risk to which client? 1. A female with an abdominal hysterectomy 2. A male who had a right upper lobectomy 3. An adolescent with an open appendectomy 4. An elderly client who had cataract removal

The primary healthcare provider's prescription for a client instructs the nurse to give digoxin 0.125 mg intravenously as a one-time dose. The available medication is in a concentration of 0.25 mg/2 mL. How many milliliters should the nurse give? Round answer using one decimal point.

What is the priority nursing action for a pregnant client in labor who is having an epidural catheter inserted for pain management? 1. Perform a thorough skin prep of the insertion site. 2. Obtain the client's consent for the procedure. 3. Assure the client that residual effects of the procedure won't be felt. 4. Monitor maternal blood pressure.

What is the priority nursing intervention when caring for a client with an eating disorder? 1. Encourage the client to cook for others 2. Weigh the client daily and keep a journal 3. Restrict access to mirrors 4. Monitor food intake and behavior for one hour after meals

What should the chemotherapy infusion nurse recognize as the major barrier of chemotherapy success in treating cancer clients? 1. Inadequate knowledge of the side effects of chemotherapy 2. Difficulty obtaining an IV access 3. The development of alopecia 4. Toxicity to normal tissues

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

Which client with a heat-related illness should the emergency room nurse provide attention to first? 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

Which initial behavior by the client on a mental health unit demonstrates to the nurse that the client is assuming responsibility for anger management? 1. Plans to use exercise to work off anger. 2. Apologizes to those individuals to whom anger has been directed. 3. Develops a plan on how to react when feeling stressed. 4. Identifies stressors of past violent behavior.

Which is an example of a sentinel event? 1. The terminally ill client is referred to hospice and dies 3 months later. 2. A client has a mammogram which reveals small cyst. 3. A client with a laceration to the knee falls when getting up unassisted after being instructed to remain in bed. 4. A client scheduled for knee replacement surgery has an above the knee amputation performed.

A client with a history of congestive heart failure (CHF) has been admitted with digoxin toxicity. After reviewing the initial laboratory results, the nurse knows what abnormal findings most likely contributed to the digoxin toxicity? Exhibit 1. Sodium 2. Calcium 3. Albumin 4. Potassium 5. Magnesium

4,5

A homecare nurse is visiting a client with advanced Alzheimer's disease living in the home of a daughter. The household includes two adults and three adolescents with extremely busy schedules. The daughter admits to feeling overwhelmed but is fearful of placing the client into a permanent care facility. What interventions by the nurse would be most helpful for the family at this time? 1. Call Adult Protective Services and ask for recommendations. 2. Request the primary healthcare provider to order placement. 3. Provide the family with brochures from various nursing homes. 4. Encourage family to join a local Alzheimer's Support Group. 5. Talk with daughter regarding fears or concerns about placement.

4,5

In which situation should the nurse consult the client's advanced directive? 1. Client scheduled for breast reconstruction after mastectomy. 2. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 3. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused.

4,5

The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? 1. Restricting oral fluids until the gag reflex has returned. 2. Encouraging early ambulation and deep breathing exercises. 3. Discontinuing medicines following percutaneous intervention. 4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

4,5

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? 1. Teach caregivers memory enhancement aids. 2. Evaluate client's safety risk factors. 3. Make referrals to community services. 4. Determine caregiver's stress level and coping strategies. 5. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

5,6

The primary healthcare provider prescribes: Ceftriaxone sodium 50 mg/kg intramuscular now. The client weighs 22.5 pounds. According to the manufacturer's instructions, the concentration is 100 mg/mL. How many milliliters (mL) should the nurse administer? Provide your answer using numbers and decimal points only. Do NOT include words. (Round to the nearest tenth)

5.1

A client is prescribed 1.5 grams of levodopa daily. Available forms of this drug include tablets of 250 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report.

This is the correct order

A six month old infant has been admitted with a diagnosis of meningococcal meningitis. The primary healthcare provider has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions? Place client on droplet precautions. Start IV of D 5 ¼ NS at 25 mL/hr. Draw blood cultures every 8 hours x 3. Prepare client for lumbar pucture. Administer ceftriaxone 250 mg IV TID.

This is the correct order

In what order should the nurse assess assigned clients following shift report? Place in priority order. Elderly client admitted 30 minutes ago with reports of constipation for four days. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift.

This is the correct order

In what order should the nurse assess assigned clients following shift report? What would be the priority order? Client reporting shortness of breath after receiving a bronchodilator respiratory treatment. Client two hour post lobectomy. Newly admitted client diagnosed with esophageal cancer. Client on ventilator needing a nasogastric tube feeding. Client with emphysema who has a pulse oximetry reading of 89%.

This is the correct order

The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

This is the correct order

The nurse is demonstrating ostomy care to a client with a new stoma in the sigmoid area of the colon. The nurse knows teaching is successful when the client completes care in what order? Remove ostomy bag and old flange. Wash stoma with warm soapy water. Apply skin protectant and allow drying. Cut center of new flange to fit stoma. Place stoma adhesive onto new flange. Press flange into place and attach bag.

This is the correct order

The triage nurse in the emergency department is prioritizing the client care for new clients. What is the correct order in which the clients should be evaluated? Infant having a tonic-clonic seizure. Elderly client rating intermittent substernal chest pain a 4 on a 10-point pain scale. Adult reporting right lower quadrant abdominal pain. Child who has a laceration to the hand with bleeding controlled by pressure. Teenager with a blood glucose of 108 mg/dL (6 mmol/L).

This is the correct order

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