Hurst Review Questions (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?"

1. "You are anxious about the pathology report?"

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."

1. "You are feeling all alone."

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.

1. 18 year old who sustained a compound fracture.

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.

1. A private room on the gynocological unit.

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? Select all that apply 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. Abrasion on the client's forehead 3. Client's confused state 4. Presence of urine on the floor 5. Side rails were up

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

1. Alanine aminotransferase (ALT)

The nurse is caring for a client diagnosed with Guillain-Barre' Syndrome. What assessment finding would the nurse expect see in this client? Select all that apply 1. Areflexia 2. Dysphagia 3. Hemiplegia 4. Orthostatic hypotension 5. Hypertonia

1. Areflexia 2. Dysphagia 4. Orthostatic hypotension

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

1. Aromatherapy

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.

1. Ask the student about the bruises on the arms and ears.

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.

1. Below the umbilicus, on the mother's left side.

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

1. Blank affect. 2. Decreased ability to swing arms. 5. Pill-rolling tremor. 6. Stiff muscles.

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? Select all that apply 1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 3. Electroencephalogram (EEG) 4. Alanine Aminotransferase (ALT) 5. Electrocardiogram (ECG)

1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 5. Electrocardiogram (ECG)

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? Select all that apply 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. 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. 5. Orthostatic hypotension can be caused by cannabis ingestion.

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.

1. Changing a colostomy bag.

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

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

1. Cough 3. Fever 4. Myalgia 5. Pleuritic chest pain

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.

1. Daily intake of St. John's Wort.

What nursing interventions are appropriate to prevent respiratory acidosis? Select all that apply 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. Deep breathing exercises 3. Incentive spirometry every 2 hours 4. Elevate the head of bed

The nurse is caring for a client diagnosed with myasthemia gravis. What assessment finding would the nurse expect to see in this client? Select all that apply 1. Difficulty chewing 2. Drooping eyelids 3. Facial paralysis 4. Hoarseness 5. Limb rigidity 6. Trouble talking

1. Difficulty chewing 2. Drooping eyelids 3. Facial paralysis 4. Hoarseness 6. Trouble talking

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? Select all that apply 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB

1. Digoxin level 2. Potassium level 3. PT/INR

What should the nurse include about transmission of the chickenpox virus while teaching a group of parents about the importance of vaccination? Select all that apply 1. Direct contact 2. Indirect contact 3. Airborne 4. Droplet 5. Common vehicle

1. Direct contact 2. Indirect contact 3. Airborne

A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in this teaching session? Select all that apply 1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables.

1. Discard the outer leaves of lettuce. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables.

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

1. Dry mucous membranes 2. Fruity-smelling breath 4. Glycosuria 5. Client report of abdominal pain

Which clinical manifestations would a nurse expect to find in a client who has sustained a flail chest injury? Select all that apply 1. Dyspnea 2. Crepitus 3. Paradoxical chest wall movement 4. Chest pain on inspiration 5. Shallow respirations 6. Bradycardia

1. Dyspnea 2. Crepitus 3. Paradoxical chest wall movement 4. Chest pain on inspiration 5. Shallow respirations

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? Select all that apply 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. 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.

The nurse is reviewing some clients' prescriptions. Which prescription should the nurse question and have corrected? Select all that apply 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. 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

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

1. Hypokalemia

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbant position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

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.

1. Inspect the wound daily for any changes

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. Select all that apply 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. Keep water by the bedside 2. Place a plastic cover over the pillow 4. Keep a change of linen in the room

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? ABG's : pH 7.48 PaCO2 38 HCO3 30 1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis

1. Metabolic alkalosis

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

1. Nonmaleficience

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.

1. Notify dietary no fresh, unpeeled fruits or vegetables.

The nurse is preparing to administer a dose of ondansetron 0.15 mg/kg. 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 ondansetron? Select all that apply 1. Nystagmus 2. Concurrent use of apomorphine 3. Pill rolling movement 4. Tachycardia 5. Maximum dose 16 mg 6. Elevated liver enzymes

1. Nystagmus 3. Pill rolling movement

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

1. Pancytopenia 3. Erythema 5. Fatigue

A nurse is planning to conduct primary prevention classes in a local community. Which initiatives should the nurse include? Select all that apply 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. Parenting classes for first time parents 2. Healthy diet classes for school-age children 5. Community exercise classes to promote weight loss

The nurse, caring for a client who has terminal cancer, finds that the client is extremely restless. In response to this data, what would be the appropriate nursing action? Select all that apply 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.

1. Play soothing music. 2. Use chamomile aromatherapy. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.

What actions would be appropriate for a nurse who is administering ear drops to a six year old child? Select all that apply 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. Position supine with affected ear up. 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.

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? Select all that apply 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. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.

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

1. Remove air from the pleural space

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? 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

1. Renal

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? Select all that apply 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. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong."

The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? Select all that apply 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium

1. Taking a shower or bath 3. Working around high voltage equipment 4. Being screened at airport security

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.

1. Teens need about 8 to 10 hours of sleep each night.

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

1. Uncontrolled diabetes 2. Alcohol abuse 4. Rheumatoid arthritis 5. Varicella-zoster virus

The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? Select all that apply 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? Select all that apply 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. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 5. Use sterile forceps when cleaning the wound.

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? Select all that apply 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

1. White grape juice 2. Gelatin 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

The night nurse has reported to the day nurse that a client has not had a bowel movement in 2 consecutive days. What actions should the day nurse take? Exhibit not available Select all that apply 1. Write prescription to initiate "Bowel Protocol" per standing order. 2. Offer client 120 mL prune juice. 3. Give Milk of Magnesia (MOM) 30 mL po. 4. Administer bisacodyl suppository. 5. Provide sodium phosphate enema.

1. Write prescription to initiate "Bowel Protocol" per standing order. 2. Offer client 120 mL prune juice.

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 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? Select all that apply 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. "Doing a monthly breast self-exam will help me learn what is normal for me." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge."

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?"

2. "Tell me how you felt when that situation occurred."

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

2. 30

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.

2. 54 year old male who abuses alcohol.

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

2. A primigravida admitted with a diagnosis of placenta previa

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

2. Administer oxygen at 2 L/nasal cannula

The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? Select all that apply 1. Limit TV viewing and video game playing to 4 hours a day 2. At least 60 minutes of moderate-intensity activity daily 3. Exercise should be structured 4. A strict diet should be followed avoiding all junk food and drinking water only 5. Set a goal of at least 11,000 to 13,000 steps each day

2. At least 60 minutes of moderate-intensity activity daily 5. Set a goal of at least 11,000 to 13,000 steps each day

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 6. Urine output at 50 mL/hr

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? Select all that apply 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. 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. 6. Make sure the tattoo artist removes the needle and tubes from sealed packages.

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

2. Cephalic vein

The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? Exhibit 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.

2. Clarify the prescription with the primary healthcare provider.

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? Select all that apply 1. Memory loss 2. Difficulty focusing 3. Excessive sleepiness 4. Short-tempered 5. Hand-wringing

2. Difficulty focusing 4. Short-tempered 5. Hand-wringing

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.

2. Discuss the plan of care with the client, family, and curandero.

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.

2. Dress in loose, comfortable clothing.

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

2. Elevate the foot of the bed.

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

2. Fever of 102.0º F

Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply 1. First intercostal space right 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. Third intercostal space in the midclavicular line to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

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.

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.

2. I'll have to drink contrast while x-rays are taken.

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.

2. Increase the flow rate of the irrigation solution until the urine is a light pink.

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply 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. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 6. Smoking cessation.

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? Select all that apply 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. Instituting contact precautions for all who enter the client's room 4. Dedicating equipment for use only in the client's room.

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.

2. Jackson Pratt drain has 90 mL of blood.

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

2. Melatonin

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? Select all that apply 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. Place pillows under lower extremities to raise heels off the bed. 4. Apply emollients to dry skin. 5. Place a gel seat cushion on the wheelchair seat.

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

2. Prealbumin

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.

2. Properly reposition every 2 hours.

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

2. Reports shortness of breath

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.

2. Restlessness and dizziness.

A primagravida asks the nurse about the purpose of the RhoGam injection. What would be the best explanation by the nurse? 1. RhoGam changes the RH positive fetus to Rh negative. 2. RhoGam prevents the mother from forming Rh antibodies. 3. RhoGam inhibits Rh antibodies in the newborn infant. 4. RhoGam destroys antibodies in the RH positive mother.

2. RhoGam prevents the mother from forming Rh antibodies.

A client is admitted to the emergency department with digoxin toxicity. Nursing assessment reveals cool skin, a slow, weak pulse, and a BP of 86/44. What initial action should the nurse take based on the assessment and cardiac rhythm strip? Exhibit 1. Administer sodium nitroprusside 0.3 mcg/kg/min IV. 2. Set up for transcutaneous pacing. 3. Have client perform vagal maneuver. 4. Draw blood for potassium level.

2. Set up for transcutaneous pacing.

A preeclampsia client is being treated with magnesium sulfate. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. What is the nurse's priority action? 1. Place client in Trendelenburg position and apply oxygen. 2. Stop magnesium and prepare to give calcium gluconate. 3. Ask another nurse to verify the deep tendon reflexes. 4. Prepare client for an emergency cesarean section.

2. Stop magnesium and prepare to give calcium gluconate.

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.

2. The mother will need frequent follow up Pap smears.

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? 15 drops/min

25

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.

28 1000/720 X 20 = 27.777 = 28

The nurse is teaching a family member of a client with a terminal illness the signs of impending death. Which statement by a family member indicates the need for further teaching? 1. "I will continue to talk in normal tones." 2. "Decrease in respirations may happen." 3. "Death is soon, if their shoulders are cool." 4. "They may prefer to sleep rather than talk."

3. "Death is soon, if their shoulders are cool."

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."

3. "I will not let others drink from my glass."

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."

3. "It is hard to deal with so many changes at once."

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."

3. "Let's find a quiet place to sit and talk awhile."

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.

3. Able to sit, leaning forward on both hands.

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.

3. Absolute neutrophil count of 400/mm3 in a child with fever.

A client admitted for placement of heart stents was started on clopidogrel. The nurse knows that a daily assessment of this client should include what data? Select all that apply 1. Monitoring of intake and output 2. Check daily liver function tests 3. Assess stools for tarry appearance 4. Monitor daily platelet count 5. Assess for new ecchymosis

3. Assess stools for tarry appearance 4. Monitor daily platelet count 5. Assess for new ecchymosis

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

3. Baseball

A client being prepared for surgery is to be given a pre-operative medication. What is the nurse's priority action when administering the medication? 1. Verify client has signed all consent forms. 2. Escort the client to the bathroom to void. 3. Check that identification band is in place. 4. Raise side rails and put call bell in place.

3. Check that identification band is in place.

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.

3. Clients with a predictable outcome.

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.

3. Complete TB medication regimen.

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

3. December 10

A client admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis is scheduled for the insertion of a pigtail catheter. The family asks the nurse the purpose of the catheter. What should the nurse tell the family? 1. Obtains an hourly assessment of urinary output. 2. Instills antibiotics to decrease internal bacteria. 3. Drains excess fluid from the abdominal cavity. 4. Obtains liver tissue for a diagnostic biopsy.

3. Drains excess fluid from the abdominal cavity.

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.

3. Encourage clients and families to develop mutually appropriate visitation times.

Which arterial blood gas value would the nurse expect to see when monitoring a client in a hyperosmolar hyperglycemic state (HHS). 1. pH 7.32 2. PaCO2 47 3. HCO3 22 4. PaO2 78

3. HCO3 22

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.

3. Has injuries in various stages of healing.

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)

3. Hematocrit of 18%

What measures should the school nurse implement for a child diagnosed with peanut allergies? Select all that apply 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. 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.

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.

3. Offer to move the roommate to another room in a quieter area.

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? Select all that apply 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. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave.

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

3. Presumptive

A nurse is assessing a terminally ill client who is restless with an O2 saturation of 58 mm Hg. Which nursing intervention would the nurse implement? 1. Monitor the client's breathing pattern 2. Wipe the mouth with oral care sponge 3. Soothe the client by affirming your presence 4. Initiate oxygen via nasal cannula at 4 L/minute

3. Soothe the client by affirming your presence

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.

3. The client is being taught self-advocacy.

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? Select all that apply 1. Skin turgor 2. Bowel sounds 3. Urinary output 4. Pupillary reaction 5. Peripheral edema 6. Level of consciousness

3. Urinary output 5. Peripheral edema 6. Level of consciousness

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.

3. Withdraws medication using a 22 gauge needle.

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. [Picture not available]

36

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.

4

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."

4. "A long-term prescription of clonazepam should be discontinued gradually."

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?"

4. "I can't keep a secret like that. Are you planning to harm yourself?"

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."

4. "I will be asked to perform a repetitive movement to test my muscles."

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."

4. "It may be worse to suddenly stop the medication than to take the medication."

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."

4. "We need to prepare high calorie, high fat meals."

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.

4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours.

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.

4. Apply intermittent warm, moist soaks to affected area.

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.

4. Ask the UAP to demonstrate how to use the lift.

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.

4. Assign same staff to provide client care daily.

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.

4. Circulate air under the cast utilizing a blow dryer on the cool setting.

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.

4. Client on heparin drip reporting bleeding gums when brushing teeth.

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.

4. Client with history of congestive heart failure coughing up pink frothy sputum.

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.

4. Close the door and quietly reorient client to current location.

In which situation should the nurse consult the client's advanced directive? Select all that apply 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. Comatose client with end stage chronic obstructive pulmonary disease. 5. Client diagnosed with inoperative brain tumor who is confused.

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

4. Coping mechanisms

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? Select all that apply 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. Encourage family to join a local Alzheimer's Support Group. 5. Talk with daughter regarding fears or concerns about placement.

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.

4. Identifies stressors of past violent behavior.

Which action by the nurse is most likely to result in a possible breach of confidentiality of medical records? 1. Entering the data on clients only at computers in nurse's station. 2. Recording the client history of an abortion. 3. Sharing access controls like passwords with other healthcare professionals. 4. Leaving the computer terminal before logging off.

4. Leaving the computer terminal before logging off.

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

4. Monitor food intake and behavior for one hour after meals

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.

4. Notify the healthcare provider.

A 3 year old child is being treated for asthma. The child weighs 31.5 lb (14.3 kg). The primary healthcare provider has prescribed Albuterol syrup 5 mg PO every 8 hours. What action should the nurse take? Albuterol Classification: Beta 2 Agonist Dosing: 2-6 years: 0.1 mg (0.25 mL)/kg PO q8hr initially, not to exceed 2 mg (5 mL) q8hr; if necessary, may be increased to 0.2 mg/kg PO q8hr, not to exceed 4 mg (10 mL) q8hr 1. Administer the dose immediately to relieve respiratory efforts. 2. Split the dose in two equal parts and administer every 4 hours. 3. Notify the charge nurse that the child needs a different type medication. 4. Notify the primary healthcare provider.

4. Notify the primary healthcare provider.

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 27, 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

4. October 3, 2020

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.

4. Provide additional information as requested by the client concerning nourishment.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4. Respiratory alkalosis

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

4. Reverse Trendelenburg

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.

4. Send written summary of client needs to facility.

What should the summer camp nurse include when teaching a group of adolescents about West Nile Virus? 1. Antiviral medications are used to treat West Nile Virus. 2. Using insect repellent containing diethyltoluamide (DEET) will kill the virus when a mosquito makes skin contact. 3. Nothing can be done to prevent West Nile Virus. 4. Symptoms of West Nile Virus include headache, fever, and fatigue

4. Symptoms of West Nile Virus include headache, fever, and fatigue

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.

4. The medication keeps me out of the hospital, and I don't want to hear voices again.

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

4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

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.

4. Use the mechanical lift and with another UAP, transfer the client to the chair.

A nurse is caring for a pediatric client who has been diagnosed with hypothyroidism. What is essential for the nurse to teach the parents of this child? 1. Administer the liquid medication with soy milk. 2. Notify primary healthcare provider of slow heart rate. 3. Monitor glucose before meals and at bedtime. 4. Wait 4 hours after giving medication before giving iron supplements.

4. Wait 4 hours after giving medication before giving iron supplements.

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.

42

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)

5

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? Select all that apply 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. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

The nurse is preparing to administer a unit of packed red blood cells (PRBCs) using a blood administration set. During the first 15 minutes of administration, the unit is to run at 25 mL / hour. How many gtts/min will the nurse need to set the IV rate at? Round to the nearest whole number. Use numbers only. 20gtts/min

8 (25 x 20 / 60 min) = 500/60 = 8.33 OR 8gtts/min

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

a. Client reporting a headache and has a fruity breath. c. Client eating a simple-carb snack due to weakness. b. Client scheduled for a dressing change to foot ulcer. d. Client to receive dietary education.

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

c. With cane on stronger side of body, support body weight with both legs. b. Move cane forward 6-10 inches (15 - 25 cm). d. Advance weaker leg forward toward the cane. a. Advance stronger leg forward toward cane.

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

d. Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). b. Client one day post splenectomy. a. Client diagnosed with cancer who is crying and states, "I am not ready to die". e. Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. c. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk.

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. a. Pull suture out with forceps. b. Gently cut the suture. c. Put suture on clean gauze. d. Make certain all suture material is removed. e. Place the curved tip of suture scissors directly under the knot. f. Document date, time, and number of sutures removed. g. Moisten dried crust with sterile 0.9% sodium chloride solution. h. Apply sterile wound strips. i. Gently grasp the knot with forceps and raise it slightly. j. Clean suture line with antimicrobial solution.

g. Moisten dried crust with sterile 0.9% sodium chloride solution. j. Clean suture line with antimicrobial solution. i. Gently grasp the knot with forceps and raise it slightly. e. Place the curved tip of suture scissors directly under the knot. b. Gently cut the suture. a. Pull suture out with forceps. d. Make certain all suture material is removed. c. Put suture on clean gauze. h. Apply sterile wound strips. f. Document date, time, and number of sutures removed.