Missed
A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.
*1. Tea 2. Crackers *3. Ice cream 4. Scrambled eggs *5. Cream of tomato soup *6. Cream of wheat cereal
The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.
*1. The client with renal failure 2. The client with an ileostomy *3. The client with chronic cirrhosis 4. The client with a draining abdominal wound 5. The client with a nasogastric tube to low suction
Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?
"You will be positioned on your back and turned slightly to one side with your head elevated."
A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency? Select all that apply.
*1. Albumin 2.2 g/dL 2. Calcium, 10 mg/dL 3. Sodium, 138 mEq/L *4. Transferrin, 90 mg/dL *5. Prealbumin 10 mg/dL
The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply.
*1. Eggs 2. Beef 3. Pork 4. Raisins *5. White bread with butter
The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply
*1. Eggs 2. Beans 3. Cereal 4. Oranges *5. Chicken 6. Broccoli
A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.
*1. Get plenty of sleep and rest. *2. Take all medications as prescribed. 3. Eat plenty of fresh fruits, salads, and vegetables. *4. Wash your hands frequently with antibacterial soap. 5. Having indoor plants is permissible, but no outdoor gardening. *6. Contact the primary health care provider (PHCP) if even a low-grade fever develops.
The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply.
*1. Hemoglobin (Hgb) 8.8 g/dL *2. Hematocrit (Hct) 30% 3. Platelet count 300,000 mm3 4. White blood count (WBC) 7500 mm3 *5. Decreased mean corpuscular volume (MCV) 66 fL
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.
*1. Platelets 35,000 mm3 (35 × 109/L) *2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) *4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 mcmol/L) *6. White blood cells, 3000 mm3 (3.0 × 109/L)
A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.
*1. Restraints 2. Nasal cannula 3. Suction catheter 4. Padded side rails *5. Padded tongue blade
A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce? Select all that apply
*1. Wash soiled clothes in hot water. 2. Disinfect surfaces with 100% bleach. *3. Use gloves when handling body fluids. 4. Encourage a minimum of 12 hours sleep per day. 5. Other members of the household should not share a bathroom. *6. Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.
The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.
*1. Wearing gloves when emptying the client's bedpan *2. Keeping all linens in the room until the implant is removed *3. Wearing a film (dosimeter) badge when in the client's room *4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway
The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse should prepare to administer how many mL to the client? Fill in the blank.
0.75 mL
The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply.
1. Alopecia 2. Back pain 3. Painless testicular swelling 4. A heavy sensation in the scrotum 5. Elevation in prostate specific antigen (PSA) levels Correct Answer: 1, 5
The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all that apply.
1. Preterm labor 2. Postterm labor 3. Maternal anemia 4. Oligohydramnios 5. Gestational diabetes Correct Answer: 1, 3
The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply.
1. "I should not suddenly stop taking this medication." 3. "Good oral hygiene is needed, including brushing and flossing."
A client has been diagnosed with open-angle glaucoma. Which signs and symptoms are found in open-angle glaucoma? Select all that apply.
1. Blurred or hazy vision 3. Tonometry reading 30 mm Hg
The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply.
1. Needle-stick injuries 3. Transmission by breast milk 5. Inconsistent use of protective equipment
The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.
1. Presence of Chvostek's sign 2. Presence of muscle weakness 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes
The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply
1. "I may not eat anything during the test." *2. "I can at least drink fluids during the test." *3. "I have 30 minutes to drink the glucose load." 4. "I may not smoke for the duration of the test." 5. "I will have blood drawn every 30 minutes for the next 2 hours." *6. "I will have blood drawn every 5 minutes for the next 3 hours."
The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply.
1. "I need to apply the cold pack for at least 60 minutes." *2. "I will remove the ice pack if I start to feel numbness." 3. "I should check my pulse before using the ice on my joints." 4. "I can lie on the ice by placing it between the bed and my body." *5. "I should wrap the frozen ice pack in a towel to help adjust to the cold."
The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?
1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses should the nurse make to the client? Select all that apply.
1. "It maintains the uterine lining for implantation." 2. "It prevents the involution of the corpus luteum." 3. "It stimulates the breasts to prepare for lactation." 4. It stimulates metabolism of glucose and converts the glucose to fat." 5. "It maintains the production of progesterone until the placenta is formed." 6. "It stimulates uterine development to provide an environment for the fetus." Correct Answer: 3, 6
The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply.
1. "The loss of electrolytes is greater than the loss of water." 2. "The loss of water is greater than the loss of electrolytes." 3. "Serum sodium level rises above 150 mEq/L (150 mmol/L)." 4. "The client is likely to have impaired mental status due to low sodium levels." *5. "Water and electrolytes are lost in approximately the same proportion as they exist in the body." *6. "A client who has a large blood loss due to an accident will initially have an isotonic dehydration."
The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply.
1. Absent bowel signs *2. Increasing restlessness *3. A pulse rate of 108 beats per minute *4. A blood pressure (BP) of 88/58 mm Hg *5. Increasing pain unrelieved by analgesics
The child is diagnosed with tinea capitis of the scalp. Oral griseofulvin has been prescribed for the child, and the nurse provides instructions regarding the administration of the medication. Which instructions should the nurse include to the mother?
1. Administer the medication with milk.
The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply.
1. Auscultate breath sounds. *2. Review vital signs from previous hour. *3. Observe the urinary catheter for patency and flow. *4. Observe the IV site for patency and correct flow rate. *5. Review when the client last received pain medication.
The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply.
1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 3. Monitoring central venous pressure every shift 4. Using an electronic infusion pump with the infusion 5. Applying sequential compression devices (SCD) to the legs 6. Reviewing prescribed blood laboratory values including electrolytes Correct Answer: 1, 2, 4, 6
Which diagnostic tests indicate active tuberculosis? Select all that apply.
1. Chest x-ray 3. Gastric analysis washings 4. Sputum smear and culture
The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.
1. Clean towel 2. Sterile gloves 3. Water-soluble lubricant 4. Sterile 5- or 6-mL syringe 5. Sterile 10- or 12-mL syringe Correct Answer: 1, 5
The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.
1. Crutches were fitted for a person who is the same height. 2. Handgrips are positioned so the axillae bear the weight of the client. *3. Handgrips are positioned so the elbows are bent approximately 30 degrees. *4. The space between the axilla and the top of the crutch pad is 1½ to 2 inches. *5. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.
The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take?
1. Document the assessment.
The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.
1. Dried fruits are good for snacks. 2. Use eggs as a source for protein. 3. Limit cereals and bread products. 4. Avoid eating lunch meats and bolognas. 5. Eat salads with cabbage and lettuce and avoid spinach Correct Answer: 2, 4, 5
The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply.
1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck Correct Answer: 3, 5
The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions should be included in the plan of care? Select all that apply.
1. Elevate the right arm on one or two pillows. 2. Do not check the radial pulse in the right arm. 3. Use small-gauge needles if the IV is initiated in the left arm. 4. Instruct the client to avoid bending the fingers of the right hand. 5. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm. Correct Answer: 1, 5
The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply.
1. Elevated serum creatinine level 2. Elevated thrombocyte cell count 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WBC) count 5. Elevated blood urea nitrogen (BUN) level Correct Answer: 1, 3, 5
The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply.
1. Ensure the client doesn't bend the hips beyond 120 degrees. 2. Ensure the client doesn't sit or stand for long periods of time. 3. Ensure the client engages in rigorous exercise to maintain strength. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living. Correct Answer: 2, 4, 5
A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply.
1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal cookies Correct Answer: 1, 2, 4
The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.
1. Fish *2. Yogurt 3. Potatoes 4. Chicken 5. White bread *6.Cottage cheese
A client is scheduled to receive chemotherapy with a group of medications, one of which is asparaginase. The nurse anticipates that this medication should be removed from the regimen after noting which findings in the client's medical record? Select all that apply.
1. History of pancreatitis 2. History of heart failure 3. History of thyroidectomy 4. Chronic obstructive lung disease 5. Significantly elevated serum amylase Correct Answer: 1, 5
The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to potential problems specifically related to the twin pregnancy? Select all that apply.
1. Hypertension 2. Elevated blood glucose levels 3. Uterine size is large for gestational age 4. Six or more uterine contractions per hour 5. Mother is confirmed as blood type Rh negative Correct Answer: 1, 4
The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which should be the nurse's actions at this time? Select all that apply.
1. Increase the rate of the IV fluid. 2. Call the primary health care provider. 3. Administer a 250-mL bolus of normal saline (0.9%). 4. Check the client's overall intake and output record. 5. Gather data about the urinary catheter and check for patency. Correct Answer: 4, 5
The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.
1. Increasing restlessness 2. Capillary refill of 3 seconds in all extremities 3. Hypoactive bowel sounds in all four quadrants 4. White blood cell (WBC) count 9,500 mm3 (9.5 × 109/L) 5. Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute Correct Answer: 1, 5 ✓
The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.
1. Inner aspect of the forearm 2. Outer aspect of the forearm 3. Dorsal aspect of the upper arm 4. Away from heavy pigmentation 5. Near a visible peripheral venous vessel Correct Answer: 1, 3, 4
The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply.
1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement. 6. History of deep venous thrombosis in right leg 10 years earlier Correct Answer: 1, 2, 4, 6
A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which actions? Select all that apply.
1. Keeping the head of the bed elevated 2. Monitoring the client's oxygen saturation level *3. Increase the liter flow to 5 L per nasal cannula 4. Assisting the client to turn, cough, and deep breathe *5. Encouraging the client to breathe slowly and shallowly
The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which actions to properly care for this client for the remainder of the shift? Select all that apply.
1. Limit intake of oral fluids. 2. Withhold all pain medication. 3. Test the urine for occult blood. 4. Ambulate the client twice in the hall. 5. Observing the urine and biopsy site for bleeding. Correct Answer: 3, 5
The nurse is administering a medication intramuscularly to an assigned client. The nurse should include which actions in administering the medication? Select all that apply.
1. Massage the site after injection. 2. Use a Z-track method for administration. 3. Wear sterile gloves to administer the medication. 4. Hold the syringe as if it is a dart to insert the needle. 5. Select an appropriate injection site such as the ventral gluteus. 6. Cleanse the injection site using a back-and-forth motion with an antiseptic pad. Correct Answer: 2, 4, 5
The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included in the client's diet? Select all that apply.
1. Milk 2. Citrus fruits 3. Bread products 4. Wild caught salmon 5. Green, leafy vegetables Correct Answer: 1, 4
The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.
1. Milk and yogurt *2. Clams and mussels 3. Apples and mangos 4. Potatoes and carrots *5. Lean beef and chicken liver
The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.
1. Neutropenic precautions *2. Testing stools and urine for blood *3. Using a soft toothbrush for mouth care 4. Monitoring closely for signs of infection 5. Monitoring the temperature every 4 hours
The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply
1. New floaters 2. Improvement in vision clarity 3. Increasing redness in the eye 4. Sensation of mild grittiness in the eye 5. Pain relieved by acetaminophen 500 Correct Answer: 1, 3
The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? Select all that apply
1. Older clients 2. Obese people 3. Client with liver disease 4. Postmenopausal women 5. Clients from poor economic communities 6. Clients with cardiovascular health problems Correct Answer: 1, 2, 4, 6
The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?
1. Placement is verified on x-ray.
The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.
1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication. Correct Answer: 2, 3, 4, 5
The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which actions? Select all that apply.
1. Positioning the client supine 2. Using products with lemon or alcohol 3. Brushing the teeth with a small soft toothbrush 4. Cleansing the mucous membranes with tooth sponges 5. Having oral suction equipment at the bedside and turned on Correct Answer: 1, 2
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply.
1. Proteinuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L (3 mmol/L) Correct Answer: 2, 4
The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply.
1. Psoriasis 2. Bony deformity 3. Limited joint mobility 4. Peripheral neuropathy 5. Peripheral vascular disease 6. History of skin ulcers or previous amputation
The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.
1. Review the coagulation laboratory studies. 2. Observe the lower lumbar area for skin infections. 3. Determine whether the client is allergic to iodine or seafood. 4. Check to see the client has a signed consent for the procedure. 5.Explain to the client about assuming a prone position for the procedure. Correct Answer: 1, 2, 4
The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.
1. Rh negative mother 2. Rh negative infant 3. Rh negative father 4. Negative Coombs' test 5. Negative serum AFP test Correct Answer: 1, 4
A client is receiving lithium carbonate. The client's lithium carbonate level is 1.5 mEq/L, which indicates an early sign of toxicity. Which are some early signs/symptoms of toxicity? Select all that apply.
1. Slurred speech 2. Muscle weakness 3. Lethargy 0.7 mEq/L 4. Diarrhea 1.0 mEq/L 5. Weight gain 1.1 mEq/L 6. Blurred vision 1.7 mEq/L Correct Answer: 1, 2, 3, 4
A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?
1. TPN impairs pancreatic function and insulin production. 2. TPN increases the cortisol levels, which causes hyperglycemia. 3. TPN increases the risk for infection, which raises the blood glucose. *4. TPN contains concentrated carbohydrates and raises blood glucose.
A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and should include which instructions? Select all that apply.
1. Take the calcium carbonate with or just after meals. 2. Avoid foods such as beets, spinach, and bran in the diet. 3. Take the medication with a full glass of water (8 oz/240 mL). 4. It is permissible to swallow whole and not chew the chewable tablets. 5. It is permissible to take an extra calcium pill if the client develops tremors. Correct Answer: 1, 2, 3
The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?
1. The incision line is slightly edematous but shows no active signs of infection.
The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.
1. The membranes are ruptured. 2. The fetus is in the breech position. 3. Lesions are present on the perineum. 4. The fetus is not settled into the pelvis. 5. The pregnancy is at 41 weeks' gestation. Correct Answer: 2, 3, 4
The primary health care provider has prescribed butenafine for a client. The nurse recognizes that this has been prescribed to treat which disorder?
1. Tinea pedis
The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs an Allen's test first. The nurse recognizes that this is being done to determine the adequacy of which circulations? Select all that apply.
1. Ulnar circulation 2. Radial circulation
The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.
1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg's position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids. Correct Answer: 1, 2, 4, 6
The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all that apply.
1. Verify the preoperative laboratory studies were drawn. 2. Report any increases in blood pressure (BP) on the day of surgery. 3. Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery. 4. Instruct the client not to swallow water with oral hygiene on the morning of surgery. 5. Document that any medications the client was instructed to take before surgery are given. Answer: 4, 5
A client with acute kidney injury secondary to heart failure develops fluid volume excess. Which signs and symptoms should the nurse expect to see? Select all that apply.
1. Weak pulse 2. Weight gain 3. Decreased hematocrit 4. Distended jugular veins 5. Decreased breath sounds on auscultation 6. Decreased specific gravity with high volume Correct Answer: 2, 3, 4, 6
The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client?
1. Wrap a light roll of gauze to cover the IV site.
The insulin drip (continuous insulin infusion) is infusing at 1.5 mL per hour. There are 100 units of regular insulin in 100 mL of 0.9% NaCl. How many units of insulin will the client receive per hour? Fill in the blank. Record the answer to one decimal place.
1.5 units/hr
The nurse is providing care to a client diagnosed with multiple sclerosis. The nurse knows that which populations are affected by this disease? Select all that apply.
1.Multiple sclerosis affects women twice as often as men. 2. Native-Americans are always immune from this disease. 3. Adults who live in colder climates never acquire this condition. 4. People who had a traumatic back injury are more likely to be affected. 5. Multiple sclerosis occurs in adults between the ages of 20 and 50 years. 6. Multiple sclerosis most often affects Caucasians of Northern European ancestry. Correct Answer: 1, 5, 6
The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?
1000 calories
The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.
11.25
The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for further teaching?
2. "I will become totally deaf if I don't follow instructions."
A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
2. 15 mg/dL (5.25 mmol/L)
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding?
2. Document the finding.
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?
2. Gown and gloves
An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?
2. Provide emotional support and reassurance.
A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply.
2. Restrict fluid intake. 4. Monitor electrolytes every 24 hours
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?
2. Symmetric thigh and gluteal folds
Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? Refer to chart.
3
A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder?
3. "The disorder means there is no communication from the right atrium to the right ventricle of the heart."
The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply.
3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks.
Warfarin sodium has been prescribed for a client, and the nurse teaches the client and family about the medication. Which statement by the client indicates a need for further teaching?
3. "I will not take any over-the-counter medications except aspirin."
A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. After the nurse provides information about this procedure, the client states, "I can't urinate in front of other people. I have a 'bashful' kidney." What is the nurse's best response?
3. "You will be screened and given as much privacy as possible."
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?
3. Advance the catheter to the bifurcation and inflate the balloon.
A male client has a tentative diagnosis of urethritis. The nurse collects data from the client knowing that which are signs/symptoms of this disorder?
3. Dysuria and penile discharge
A client is receiving standard oral anticoagulant therapy with warfarin. The result of a newly drawn international normalized ratio is 3.8 seconds. The client needs to have an invasive procedure done on the next day. Which medication will likely be ordered to reverse the anticoagulant effect?
3. Phytonadione
The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?
3. Reported hopelessness
The nurse documents the following assessment findings at 1 minute following birth: heart rate, 122 beats/minute; good, lusty cry; well flexed; cries appropriately; and the body is pink with blue extremities. What should the nurse document as this newborn's 1-minute Apgar score?
9
A client receiving total parenteral nutrition (PN) has a history of heart failure. The health care provider has prescribed furosemide 40 mg orally daily to prevent fluid overload. The nurse is giving instructions about taking furosemide in relation to the client's health plan. Which statement by the client indicates a need for further teaching?
4. "I need to talk to my doctor about increasing my digoxin."
A pilocarpine ocular system is prescribed for the client with glaucoma. The nurse reinforces instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication?
4. "I should check my eye each morning to make sure that the medication system is in place.
A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia (BPH), the nurse questions the client about use of which medication?
4. Decongestants
The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?
4. Exert upward pressure against the presenting part with gloved fingers.
A client diagnosed with pleurisy is being started on medication therapy with ibuprofen. Which statement by the nurse accurately describes the purpose of the medication for the client?
4. Ibuprofen is a nonsteroidal anti-inflammatory medication to enhance coughing and deep breathing.
A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?
4. Notify the primary health care provider (PHCP) of the client's signs and symptoms.
The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?
Prolonged bed rest
A client diagnosed with hyperthyroidism will be taking propylthiouracil. The nurse reinforces medication instructions and determines that the client understands the information if the client states that it is most important to report which symptoms to the primary health care provider?
Sore Throat