N151 Final Exam NCLEX Questions (No Rationale)

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A 10-year-old boy has been admitted to the hospital with respiratory acidosis. The nurse suspects that which chronic lung disease most likely caused the child to develop this condition? A) Cystic fibrosis B) Aspiration C) Hyperthyroidism D) Pneumonia

A 22-year-old patient has presented to her primary care provider for her scheduled Pap smear. Abnormal results of this diagnostic test may imply infection with: a) human papillomavirus (HPV). b) Chlamydia trachomatis. c) Candida albicans. d) Trichomonas vaginalis.

A 32-year-old man scheduled for a unilateral orchiectomy for testicular cancer is admitted to the hospital the morning of surgery. He is accompanied by his wife but does not talk to her and does not initiate interaction with the nurse. The most appropriate action by the nurse is to a. ask the patient if he has any questions or concerns about the diagnosis and treatment. b. tell the patient's wife that concerns about sexual function are common with this diagnosis. c. teach the patient that impotence is rarely a problem after unilateral orchiectomy. d. document the patient's lack of communication on the chart and continue preoperative care.

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

A 53-year-old man tells the nurse he has not been able to function sexually for several years but is now interested in using Viagra (sildenafil). In responding to the patient's interest, the nurse a. questions the patient about any prescription drugs he is taking. b. tells the patient that Viagra is an appropriate treatment for only a few types of ED. c. asks the patient about any previous treatment for hydrocele. d. reassures the patient that a gradual decline in erectile function is common with aging.

A client has been admitted to the unit with chronic obstructive pulmonary disease. Blood gas analysis indicates respiratory acidosis. The nurse anticipates which diagnosis should be the priority for this client? A) Impaired Gas Exchange B) Ineffective Airway Clearance C) Impaired Mobility D) Anxiety

A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client's acid-base balance? A) Arterial blood gases (ABGs) B) Pulse oximetry C) Sputum studies D) Bronchoscopy

A client is brought to the Emergency Department after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A) Metabolic acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Respiratory acidosis

A client is recovering from a fractured radius that occurred 7 weeks ago. Which process of bone healing should the nurse anticipate the client to be experiencing? A. Reparative phase B. Remodeling phase C. Inflammatory phase D. Bony union phase

A client sustained a radial fracture and a cast was just applied. The client states that there is unrelieved pain and numbness in the fingers on the affected side. Which intervention should be a priority? A. Notifying the healthcare provider for cast removal B. Elevating the extremity C. Preparing for fasciotomy D. Performing frequent neurovascular checks

A client who was treated for a long bone fracture suddenly has a respiratory rate of 28 breaths/ min with an oxygen saturation of 86% on room air. The client is confused and restless. Which collaborative intervention is appropriate? A. Applying oxygen and continuing to assess respiratory status B. Intubating the client immediately C. Immediately immobilizing the pelvic area D. Administering corticosteroids as ordered

A client with a history of HSV-2 infection asks the nurse about future sexual activity. Which of the following responses would be most appropriate? a) "Inform all potential sexual partners about the infection, even if it is inactive.". b) "Use a condom during sexual activity if the infection becomes active again." c) "If the infection has healed, you probably don't have to use a condom." d) "Refrain from all sexual activity until you don't have another outbreak for a year."

A client with hyperaldosteronism has been admitted to the unit. The nurse knows the client is at risk for impaired gas exchange. Which position should this client be placed to enhance gas exchange? A) Fowler's position B) Prone position C) Left side-lying position D) Right Sims position

A client with injuries from a motor vehicle crash is intubated for respiratory support. The nurse notes that the client is fighting the ventilator and attempting to pull out the endotracheal tube. What should the nurse do to reduce this client's risk of developing respiratory alkalosis? A) Administer a sedative as prescribed. B) Apply wrist restraints. C) Teach the client to take slow, deep breaths. D) Discuss removing the endotracheal tube with the healthcare provider.

A client with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the client about compliance with taking which of the following medications that supports red blood cell (RBC) production? a) iron supplement b) zinc supplement c) calcium supplement d) magnesium supplement

A female client with an anal gonorrheal infection experiences painful bowel elimination and a purulent rectal discharge. The nurse would expect to find which of the following once the microorganism disseminates throughout the body? a) Painful joints b) Intermenstrual bleeding c) Sore throat d) Painful urination

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

A group of students are reviewing class material on sexually transmitted infections in preparation for a test. The students demonstrate understanding of the material when they identify which of the following as the cause of condylomata? a) Human papilloma virus b) Haemophilus ducreyi bacillus c) Herpes virus d) Treponema pallidum

A male client reports urethral pain and a creamy yellow, bloody discharge from the penis. The nurse associates these characteristics with which of the following sexually transmitted infections? a) Gonorrhea b) Candidiasis c) Chancroid d) Trichomoniasis

A nurse caring for a client who has begun menopause selects the nursing diagnosis of deficient knowledge when the client makes which statement? a "I must be coming down with the flu because I am having hot flashes." b "I need to begin weight-bearing exercises such as walking." c "I should increase my daily calcium intake to 1200 mg." d "I need to obtain yearly mammograms."

A nurse caring for a client with an ileostomy understands the the client is most at risk for developing which acid-base disorder? A) Metabolic Acidosis B) Metabolic Alkalosis C) Respiratory Acidosis D) Respiratory Alkalosis

A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which important parameter on a daily basis? a) weight b) albumin levels c) activity tolerance d) blood urea nitrogen (BUN) level

A nurse is developing a plan of care for a female client experiencing her first outbreak of genital herpes. Which nursing diagnosis would the nurse most likely identify as the priority? a) Acute pain related to the development of the genital lesions b) Deficient knowledge related to the disease and its transmission c) Ineffective coping related to the increased stress associated with the infection d) Hyperthermia related to body's response to an infectious process

A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings? A) pH 7.25, Pco2 50, B) pH 7.35, Pco2 40 C) pH 7.50, Pco2 52 D) pH 7.52, Pco2 28

A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for which of the following characteristic findings of syphilis in the primary clinical stage? A) Chancre B) Alopecia C) Condylomata lata D) Regional adenopathy

A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. d. sterility will not be a problem after surgery because sperm production will not be affected.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

A patient with symptomatic BPH is scheduled for visual laser ablation of the prostate (VLAP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. to expect an immediate improvement in urinary force. d. that an intraprostatic urethral stent will be placed.

A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea has presented at the clinic. The student knows that the care plan for this patient should be include what in the treatment of gonorrhea? a) Concurrent treatment for chlamydia b) Avoidance of the use of tampons c) Vaginal smears every 6 months d) Radiation therapy to destroy cancerous cells

A woman experiencing menopause has been placed on hormone replacement therapy (HRT) by her health care provider. What information regarding HRT should the nurse provide the client? a "Hormone replacement therapy will assist in alleviating severe manifestations when used on a short-term basis." b "You can stay on HRT as long as you need it." c "You will find that HRT will improve bone density and serum lipids. " d "Hormone replacement therapy is safe for long-term use.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

An instructor is teaching a group of students about the incidence of sexually transmitted infections (STIs) and those that must be reported by law. The instructor determines that the students have understood the information when they state that which STI must be reported? a) Syphilis b) Condylomata acuminata c) Genital herpes d) Hepatitis B

A 49-year-old woman who is being seen in the clinic for her annual physical examination. After her examination, she talks about her menopausal symptoms. Which information should the nurse include regarding home care planning to assist in management of menopausal symptoms? a Maintain adequate hydration b Wear tight-fitting dark clothing c Limit sexual activity d Keep bedroom warm at night

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? A. Dehydration B. Hypokalemia C. Fluid Overload D. Hypernatremia

Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. An appropriate nursing intervention for this patient is to teach the patient a. pelvic floor muscle training. b. the use of belladonna and opium suppositories. c. how to perform intermittent self-catheterization. d. to restrict oral fluid intake.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

Katrina Sterrett, a 26-year-old preschool teacher, is being seen by a physician who is part of the internist group where you practice nursing. She is undergoing her annual physical and is having many lab tests done as a condition of her employment and upcoming wedding. She is returning for her results and is devastated to learn that she has the sexually-transmitted infection, gonorrhea. What would contribute to her ignorance of her condition? a) Being asymptomatic b) All options are correct c) Being sexually inactive d) Knowing the signs and symptoms of STIs

Mrs. Wilson is a 50-year-old woman who is being seen in the clinic for an annual physical examination. She indicates that she is tired all the time, snaps at her husband, and cannot sleep at night due to night sweats. She states that she does not smoke or drink. She is in good health after being successfully treated for breast cancer 7 years ago. She asks what can be done. What nonpharmacologic treatment would you include in your teaching regarding alleviation of menopausal symptoms? a Biofeedback b Hormone replacement therapy c Vitamin D d Bioidentical hormones

Standard precautions should be used when providing care for A) All patients regardless of diagnosis. B) Pediatric and gerontologic patients. C) Patients who are immunocompromised. D) Patients with a history of infectious diseases.

The 20 year old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications? a. "Are you sexually active, and if so, are you using birth control?" b. "Have you discussed taking these drugs with your parents?" c. "Which arm do you prefer to have an IV in for 4 days?" d. "Have you signed an informed consent for investigational drugs?"

The client comes into the emergency department saying, "I am having a heart attack" Which question is most pertinent when assessing the client? A. "Can you describe the chest pain" B. "What were you doing when the pain started" C. "Did you have a high-fat meal today" D. "Does the pain get worse when you lie down"

The client diagnosed with a myocardial infarction asks the nurse, "why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? A. "Your heart is damaged and needs about 4 to 6 weeks to heal" B. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias" C. "Your doctor has ordered bedrest. Therefore, you must stay in bed." D. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger"

The client has been diagnosed to have glomerulonephritis. What should the nurse observe in the urine? a) blood b) pus c) white blood cells d) glucose

The client has end-stage renal disease. He had undergone kidney transplant 5 days ago. Which of the following is the most important intervention for the client to prevent infection? a) observe asepsis b) increase fluid intake c) avoid clients with flu d) avoid crowded places

The client hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism. The priority action for the nurse is to: a) discontinue dialysis and notify the physician b) monitor vital signs every 15 minutes for the next hour c) continue dialysis at a slower rate after checking the lines for air d) bolus the client with 500 ml of normal saline to break up the air embolus

The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? A) "I will brush my teeth after every meal." B) "I will check my Dilantin level daily." C) "My urine will turn orange while on Dilantin." D) "I won't have any seizures while on this medication."

The client with RA has nontender movable nodules in subcutaneous tissue over the elbows and shoulders. Which statement is the best explanation for the nodules? a. The nodules indicate a rapidly progressive destruction of the affected tissue b. The nodules are small amounts of synovial fluid that have become crystallized c. The nodules are lymph nodes that have proliferated to try to fight the disease d. The nodules present a favorable prognosis and mean the client is better

The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. The nurse should immediately: a) change the dressing b) reinforce the dressing c) flush the peritoneal dialysis catheter d) scrub the catheter with povidine-iodine

The client with continuous ambulatory peritoneal dialysis (CAPD) has cloudy dialysate. Which of the following is the best initial nursing action? a) send fluid to the laboratory for culture b) administer antibiotic c) do nothing, this is expected d) stop drainage of fluid

The health care provider prescribes finasteride (Proscar) for a 56-year-old male patient who has a BPH symptom score of 12 on the AUA Symptom Index. When teaching the patient about the drug, the nurse informs him that a. his interest in sexual activity may decrease while he is taking the medication. b. he should change position from lying to standing slowly to avoid dizziness. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? A. Notify the health-care provider immediately B. Elevate the head of the client's bed C. Document this as a normal and expected finding D. Administer morphine intravenously

The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? A) "Some people have a warning that the seizure is about to start." B) "Auras occur when you are physically and psychologically exhausted." C) "You're concerned that you do not have auras before your seizures?" D) "Auras usually cause you to be sleepy after you have a seizure."

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? A. Pour into the NG tube through a syringe with the plunger removed B. Dilute with water and inject into the NG tube by putting pressure on the plunger C. Discard properly and record as output on the client's intake and output record. D. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias B. Encourage increased intake of phosphate antacids C. Discontinue any magnesium-contain medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.

The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? A) Note the first thing the client does in the seizure. B) Assess the size of the client's pupils. C) Determine if the client is incontinent of urine or stool. D) Provide the client with privacy during the seizure.

The nurse has completed discharge teaching for a client with an anxiety disorder. Which client statement indicates that client teaching about respiratory alkalosis has been effective? A) "I will see my counselor on a regular basis." B) "I will breather faster when I am feeling anxious." C) "I will eat more bananas at breakfast." D) "I will not take antacids when I have heartburn."

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? a) cream of wheat, blueberries, coffee b) sausage and eggs, banana, orange juice c) bacon, cantaloupe melon, tomato juice d) cured pork, strawberries, orange juice

The nurse is analyzing the client's arterial blood gas report, which reveals a pH of 6.58. The client has just suffered a cardiac arrest. Which of the following consequences does the nurse consider for this client? A) Decreased cardiac output B) Increase magnesium levels C) Decreased free calcium in the ECT D) Increased myocardial contractility

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? A. Hypotension B. Increased heart rate C. Bounding peripheral pulses D. Shortened QT interval on electrocardiography (ECG)

The nurse is caring for a client admitted with renal failure and metabolic acidosis. Which of the following signs would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? A) Decreased respiratory depth B) Palpitations C) Increased deep tendon reflexes D) Respiratory rate of 38

The nurse is discussing menopause with a 40-year-old client. During this discussion, the nurse identified which factor that determines when perimenopause may occur? a Genetics b Age of menarche c Being sexually active d Alcohol use

The nurse is giving a presentation about chlamydia to a group of adult women. The nurse would emphasize the need for annual screening for this infection in all sexually active women younger than which age? a) 26 b) 35 c) 18 d) 32

The nurse is planning care for a client who has been admitted to the unit with a salicylate overdose. When preparing the plan of care, the nurse considers which to be a priority nursing diagnosis? A) Ineffective Breathing Pattern B) Powerlessness C) Risk for Injury D) Impaired Mobility

The nurse is preparing a presentation for a local community group about sexually transmitted infections (STIs). Which of the following would the nurse expect to include as the most common STI in the United States? a) Chlamydia b) Syphilis c) Genital herpes d) Gonorrhea

The nurse is preparing to administer morning medications. Which medication should the nurse administer first? a. The pain medication to a client diagnosed with RA b. The diuretic medication to a client diagnosed with Lupus (SLE) c. The steroid to a client diagnosed with polymyositis d. The appetite stimulant to a client diagnosed with OA

The nurse is providing care to a client recently extubated for treatment of aspiration pneumonia and respiratory acidosis. Which action by the nurse provides an optimum environment for this client? A) Allowing family members to remain with client as much as possible B) Restraining the client C) Placing the client in a side-lying position D) Administering narcotics for pain

The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? A. The Skin B. Urinary Output C. Wound Drainage D. The gastrointestinal tract

The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? A. Discuss the order with the health-care provider B. Take the client's apical pulse rate before administering C. Check the client's potassium level before giving the medication D. Determine if a digoxin level has been drawn

The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? A) Ensure that helmets are worn in appropriate areas. B) Implement daily exercise programs for the staff. C) Provide healthy foods in the cafeteria. D) Encourage employees to wear safety glasses.

The occupational health nurse is teaching a class on the risk factors for developing OA. Which is a modifiable risk for developing OA? a. Being overweight b. Increasing age c. Previous joint damage d. Genetic susceptibility

The physician orders a combination of Sulfamethoxazole and Phenazopyridine hydrochloride (Azogantrisol) for a patient. Which therapeutic effect should this combination drug have: a) plain relief and a decreased WBC count b) equal fluid intake and output c) polyuria with reddish stain d) increased complaints of bladder spasm after 20 minutes

When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority? a) Risk for infection related to altered immune cell function b) Impaired skin integrity related to persistent deep skin abscesses c) Anxiety related to an inherited disorder d) Grieving related to the poor prognosis of the condition

When planning teaching for a patient who has had a unilateral orchiectomy and chemotherapy for testicular cancer, the nurse will include information about the need for a. regular follow-up appointments to detect other types of malignancies. b. aspiration of sperm from the remaining testis if infertility occurs. c. testosterone supplements to help maintain erectile function. d. application of ice to the scrotum to minimize pain and swelling.

When teaching a patient infected with HIV regarding transmission of the virus to others, which of the following statements made by the patient would identify a need for further education? A) "I will need to isolate any tissues I use so as not to infect my family." B) "I will notify all of my sexual partners so they can get tested for HIV." C) "Unprotected sexual contact is the most common mode of transmission." D) "I do not need to worry about spreading this virus to others by sweating at the gym."

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? A. Heart Failure B. Activity intolerance C. Powerlessness D. Anticipatory grieving

Which of the following client responses shows a correct understanding of continuous ambulatory peritoneal dialysis (CAPD)? a) I am expected to perform the procedure at home b) the procedure lasts for one hour c) I have to sit and raise my legs during the procedure d) I have to go to the hospital for this procedure

Which of the following is an expected finding in the client with chronic renal failure? a) anemia b) polyuria c) increased creatinine clearance d) increased serum calcium levels

Which of the following problems is expected in a client who is in end-stage renal failure? a) anemia b) thalassemia c) renal calculi d) hypotension

Which of the following should be considered in the diet of the client with end-stage-renal-disease (ESRD)? a) limit fluid intake during anuric phase b) limit phosphorus and vitamin D-rich food c) limit calcium-rich food d) limit carbohydrates

Which of the following should the nurse include in the nursing care plan of the client who is diagnosed to have renal failure, whose BUN is 32 mg/dl, serum creatinine is 4 mg/dl, hematocrit is 38%. He is complaining of fatigue and edema. a) low protein diet and fluid restriction b) high protein diet and fluid restriction c) low protein diet and increase in fiber d) high protein diet and potassium restriction

Which population is at a higher risk for dying from a myocardial infarction? A. Caucasian Males B. Hispanic Females C. Asian Males D. African American Females

A client fell off a ladder and the healthcare provider suspects a fracture of the right wrist. Which manifestation should the nurse anticipate observing in the client? (Select all that apply.) A. Crepitus B. Visible deformity C. Pain D. Cyanosis of nail beds E. Absence of radial pulse

A, B, C

A client has been diagnosed with menopause and is complaining of increased severity of manifestations. Which treatments can be used for the treatment of menopausal symptoms? (Select all that apply.) a Hormone replacement therapy b Herbs c Acupuncture d Bioidentical hormones e Gabapentin (Neurontin)

A, B, C, D

The nurse is assessing an African-American client whose cultural background is different from the cultural background of the nurse. The client has symptoms of metabolic acidosis. Which of the following situations would illustrate stereotypical behavior on the nurse's part? (Select all that apply.) A) Understanding that all culture members will have the same beliefs B) Bringing previous negative information and experiences into this situation C) Making an assumption that all members of each culture are alike D) Taking general knowledge from literature and applying it to the situation E) Discussing the client's health status with family members

A, B, C, D

The nurse is evaluating care provided to a client with respiratory alkalosis. Which outcomes indicate that nursing care has been effective for this client? (Select all that apply) A) Respiratory rate 18 and regular B) Sleeping through the night C) Gait steady D) Consistent body weight E) Using prescribed bronchodilators

A, B, C, D

The nurse is preparing discharge instructions for an older client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. What should the nurse include in this teaching? (Select all that apply.) A) Obtain annual influenza immunization. B) Engage in frequent hand washing. C) Avoid crowds. D) Cover the nose and mouth when coughing. E) Restrict fluids.

A, B, C, D

The nurse notes that a client with a 2-day postoperative internal fixation femur fracture is a current two-pack-a-day smoker. Which complication should the nurse expect due to the client's smoking habit? (Select all that apply.) A. Osteomyelitis B. Delayed bone healing C. Higher incidence of infection D. Decreased blood circulation to bone E. Increased bone density

A, B, C, D

What are the clinical manifestations of menopause? (Select all that apply.) a Vaginal dryness b Thinning hair c Headaches d Hot flashes e Cold intolerance

A, B, C, D

Which nursing diagnosis should the nurse include when planning care for a client experiencing menopause? (Select all that apply.) a Impaired mood b Altered sleep pattern c Potential for urinary dysfunction d Increased risk of low self-esteem e Constipation

A, B, C, D

The nurse identifies the diagnosis Risk for Impaired Gas Exchange to guide the care of a client with metabolic alkalosis. What did the nurse assess to support this diagnosis? (Select all that apply.) A) Respiratory rate 8 per minute B) Oxygen saturation 89% C) Urine output 25 mL/hr D) Restlessness and agitation E) Weight loss of 3 kg overnight

A, B, D

The nurse is performing an admission assessment on an older adult male who has a suspected hip fracture. Which pre-existing situation might be found in the client? (Select all that apply.) A. Bedridden B. Over the age of 80 C. Chronic steroid use D. Wheelchair-bound E. Diabetes

A, B, D

A client had a cast applied to a fractured limb, and the healthcare provider has ordered frequent neurovascular checks. Which assessment should the nurse perform? (Select all that apply.) A. Paresthesia B. Pain C. Position D. Color E. Temperature

A, B, D, E

A female client presents to her healthcare provider's office with manifestations of menopause. What are the VASOMOTOR manifestations of menopause? (Select all that apply.) a Hot flashes b Palpitations c Decreased body hair d Night sweats e Dizziness

A, B, D, E

A nurse notes that a client's arterial blood gas reults reveal a pH of 7.50 and a Pco2 of 30. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all the apply: A) Nausea B) Confusion C) Bradypnea D) Tachycardia E) Hyperkalemia F) Lightheadedness

A, B, D, F

The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L c) the client's hemoglobin level is 10 g/dL d) the client's serum calcium is 7.7 mg/dL e) the client's serum sodium is 140 mEg/L f) the client's serum magnesium is 4 mEq/L g) the client's weight has increased from 60 kg to 63 kg

A, B, E

The nurse is caring for the client experiencing hypovolemic shock and metabolic acidosis. Which of the following therapies would the nurse question if planned for this client? (Select all that apply.) A) Monitor weight on admission and discharge. B) Monitor ECG for conduction problems. C) Limit the intake of fluids. D) Administer sodium bicarbonate. E) Keep the bed in the locked and low position.

A, C

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. A. Dehydration B. HTN C. Physiological stress D. Decreased blood volume E. Decreased plasma osmolarity

A, C, D

The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? (Select all that apply.) A) Keep a record of seizure activity. B) Take tub baths only; do not take showers. C) Avoid over-the-counter medications. D) Have anticonvulsant medication serum levels checked regularly. E) Do not drive alone; have someone in the car.

A, C, D

A 52-year-old woman complains of hot flashes, night sweats, irritability, decreased vaginal lubrication, and no menstrual period in the past 15 months. Over the past several weeks, the hot flashes and night sweats have increased in frequency, and she has noticed that she is more irritable. Laboratory values reveal increased follicle-stimulating hormone and luteinizing hormone levels. Which intervention should the nurse initiate? (Select all that apply.) a Asking open-ended questions about the client's body image b Instructing the client to avoid over-the-counter vaginal lubricants c Explaining such physiological manifestations of menopause as hot flashes and night sweats d Providing information about medications that might be prescribed to help with menopausal symptoms e Encouraging discussion of how menopausal symptoms are affecting sexual functioning

A, C, D, E

The client with an anxiety disorder is ready to be discharged from the unit. What should the nurse plan to teach this client and family in preparation for discharge? (Select all that apply) A) Refer the client for counseling. B) Instruct the client to eat foods high in acid. C) Teach the client the signs of impending panic attack. D) Advise the client to breathe into a paper bag when feeling anxious. E) Instruct the client to breathe slowly.

A, C, E

The nurse is preparing to admit a client with acute pneumonia who is experiencing severe respiratory acidosis. The nurse anticipates that treatment for this client may include which actions? (Select all that apply) A) Administer oxygen prn. B) Administer digoxin for heart failure. C) Encourage up to 3L of fluids per day. D) Place in a prone position. E) Reposition frequently.

A, C, E

The nurse is caring for a client who has been admitted to the hospital for congestive heart failure. Which data collected during the nursing assessment indicates that the client is at risk for metabolic alkalosis? (Select all that apply.) A) The client takes furosemide (Lasix) daily. B) The client takes a baby aspirin once daily. C) The client takes metformin daily. D) The client frequently uses calcium carbonate (Tums®) for acid indigestion. E) The client takes acetaminophen as needed for pain.

A, D

A client who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic ketoacidosis after a religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religion. Which nursing action would be appropriate? (Select all that apply.) A) Request a consult from a diabetes educator. B) Tell the client that things are different now because of the diabetes. C) Ask family members of the same religion to discuss fasting with the client. D) Assess the meaning and context of fasting in the client's religion. E) Encourage the client to seek medical care if signs of ketoacidosis occur in the future.

A, D, E

Which of the following risk factors exhibited by the client presenting in the Emergency Department would place the client at risk for metabolic acidosis? (Select all that apply.) A) Abdominal fistulas B) Chronic obstructive pulmonary disease C) Pneumonia D) Acute renal failure E) Hypovolemic shock

A, D, E

The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which of the following are appropriate nursing diagnoses for this client during the acute phase of the illness? (Select all that apply.) A) Decreased Cardiac Output B) Ineffective Airway Clearance C) Deficient Fluid Volume D) Knowledge Deficit E) Risk for Injury

A, E

A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. A. Ensure adequate fluid intake. B. Implement safety measures to prevent falls C. Encourage low fiber foods to prevent diarrhea. D. Instruct the client about foods that contain potassium. E. Encourage the client to obtain assistance to ambulate.

A,B, D, E

Teaching for patients with a sexually transmitted disease (STD) would include (select all that apply) A) Treatment of sexual partner is important. B) Douching may help provide relief of itching. C) Cotton undergarments are preferred over synthetic materials. D) Sexual abstinence is indicated during the communicable phase of the disease. E) Condoms should be used during as well as after treatment during sexual activity.

A,C,D,E

A 22-year-old male is being treated at a college health care clinic for gonorrhea. Which of the following teaching points should the nurse include in patient teaching? A) "While being treated for the infection, you will not be able to pass this infection on to your sexual partner." B) "While you're taking your antibiotics, you will need to abstain from participating in sexual activity or drinking alcohol." C) "It's important to complete your full course of antibiotics in order to ensure that you become resistant to reinfection." D) "The symptoms of gonorrhea will resolve on their own, but it is important for you to abstain from sexual activity while this is occurring."

A 50-year-old client confides to the nurse that she is experiencing dyspareunia during sexual intercourse. The nurse recommends which therapy for this client? a Tell the partner that sex is no longer desired. b Use a vaginal lubricant. c Consume alcohol to reduce inhibitions. d Reduce sexual contact to once a month.

A client begins to hyperventilate after learning that a breast biopsy was positive for cancer. After a few minutes, the client loses consciousness. What should the nurse do? A) Begin cardiopulmonary resuscitation. B) Raise the side rails on the bed. C) Notify the physician. D) Insert an intravenous access device.

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: a) 3 mg/dL b) 15 mg/dL c) 29 mg/dL d) 35 mg/dL

A client is being treated for gonorrhea. Which agent would the nurse expect the physician to prescribe? a) Tetracycline b) Ceftriaxone c) Penicillin d) Levofloxacin

A client is brought to the Emergency Department with rapid breathing after learning of a family member being killed in a house fire. What should the nurse do first to help this client? A) Coach to slow the breathing. B) Move to a quiet, calm environment. C) Provide a sedative. D) Ask for a psychiatric consultation.

A client is diagnosed with chlamydia and is distraught. "How can I have this problem? I don't have any symptoms!" she says. The nurse teaches the client that the percentage of women with chlamydia who are asymptomatic is as high as a) 100% b) 75% c) 50% d) 25%

A client with metabolic acidosis has been admitted to the unit from the Emergency Department. The client is experiencing confusion and weakness. Which of the following does the nurse implement as a priority of care for this client? A) Place the client in a high-Fowler's position. B) Protect the client from injury. C) Administer sodium bicarbonate. D) Give the client skin care.

A client with metabolic alkalosis is experiencing numbness around the mouth and tingling of the fingers. What should the nurse explain as the reason for these manifestations? A) "Because you are breathing so fast, the oxygen is not getting to your nerve endings." B) "Your health problem affects calcium in your body, which causes the tingling around your mouth and fingers." C) "You have a build-up of carbon dioxide in your blood." D) "You don't have enough potassium in your body, so the tingling around your mouth and fingers will occur."

A client with primary syphilis is allergic to penicillin. The nurse would expect the physician to order which agent? a) Podophyllum resin b) Tetracycline c) Ceftriaxone d) Acyclovir

A client with severe metabolic alkalosis has been admitted to the unit and is being cared for by a nursing student along with the nurse. What should the nurse say is a priority for this client? A) Administering medication for metabolic alkalosis B) Monitoring oxygen saturation C) Teaching the client the risk factors for metabolic alkalosis D) Setting goals for the client with metabolic alkalosis

A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances? A. Calcium and Chloride B. Chloride and bicarbonate C. Potassium and Phosphates D. Aluminum and magnesium

A couple is seen at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine any possible causes for infertility, the nurse will check the man for the presence of a. hydrocele. b. varicocele. c. epididymitis. d. paraphimosis.

A hospital has seen a recent increase in the incidence of hospital-acquired infections (HAIs). Which of the following measures should be prioritized in the response to this trend? A) Use of gloves during patient contact B) Frequent and thorough hand washing C) Prophylactic, broad-spectrum antibiotics D) Fitting and appropriate use of N95 masks

A male patient comes to the clinic and is diagnosed with gonorrhea. Which symptom most likely prompted him to seek medical attention? a) Painful red papules on the shaft of the penis b) Foul-smelling discharge from the penis c) Rashes on the palms of the hands and soles of the feet d) Cauliflower-like warts on the penis

A menopausal woman is taking hormone replacement therapy (HRT). The nurse teaches the client that a warning sign for endometrial cancer that needs to be reported is: A. hot flashes B. irregular vaginal bleeding C. urinary urgency D. dyspareunia

A nurse is assessing a woman with vaginal discharge. The nurse suspects bacterial vaginosis when the client states which of the following? a) "The discharge is yellowish but thin." b) "I noticed a strange fishy odor during my period." c) "The discharge looks almost like cottage cheese." d) "I've been experiencing some really intense itching."

A nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third-spacing of fluid? A. Client with a major burn B. Client with an ischemic stroke C. Client with Laennec's cirrhosis D. Client with chronic kidney disease.

A nurse is caring for a client diagnosed with a chlamydia infection. The nurse teaches the client about disease transmission and advises the client to inform his sexual partners of the infection. The client refuses, stating, "This is my business and I'm not telling anyone. Beside, chlamydia doesn't cause any harm like the other STDs." How should the nurse proceed? a) Do nothing because the client's sexual habits place him at risk for contracting other STDs. b) Educate the client about why it's important to inform sexual contacts so they can receive treatment. c) Inform the health department that this client contracted an STD. d) Inform the client's sexual contacts of their possible exposure to chlamydia.

A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicated a pH of 7.50 and a Pco2 of 30. The nurse has determines that the client is experience respiratory alkalosis. Which laboratory value would most likely be noted in this condition? A) Sodium level of 145 B) Potassium level of 3 C) Magnesium level of 2 D) Phosphorus level of 4

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? A) Metabolic Acidosis B) Metabolic Alkalosis C) Respiratory Acidosis D) Respiratory Alkalosis

A nurse is teaching a health class to a group of clients likely to be at highest risk for gonorrhea. What is the age range of the clients? a) 60 to 70 years b) 15 to 24 years c) 25 to 29 years d) 30 to 45 years

A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30, and HCO3- of 22. The nurse analyzes these results as indicating which condition? A) Metabolic Acidosis, compensated B) Respiratory Alkalosis, compensated C) Metabolic Alkalosis, compensated D) Respiratory Acidosis, compensated

A patient has herpes simplex 2 viral infection (HSV-2). The nurse recognizes that which of the following should be included in teaching the patient? a) The virus causes "cold sores" of the lips. b) Treatment is focused on relieving symptoms. c) The virus may be cured with antibiotics. d) The virus when active may not be contracted during intercourse.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

A patient with acute urinary retention associated with BPH is admitted to the emergency department. The patient has had no urine output for 16 hours, and the laboratory work shows a blood urea nitrogen (BUN) level of 50 mg/dl and a creatinine of 3.0 mg/dl. The nurse will anticipate a health care provider order tO a. schedule the patient for inpatient hemodialysis. b. insert a retention catheter. c. start an IV line for fluid administration. d. administer furosemide (Lasix).

A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "The prostate gland normally changes slightly in size from day to day, and this may be making your symptoms worse." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate?" d. "I will talk to the doctor about ordering a prostate specific antigen test."

A spouse and his client who is perimenopausal is questioning the nurse regarding self-care during this process. The nurse plans to focus teaching for this client on which priority of care? a Referring the client to a support group b Reducing the risks associated with menopause c Recommending hormonal therapy d Stressing the importance of foot care

A student nurse is caring for a male patient diagnosed with gonorrhea. The patient is receiving ceftriaxone and doxycycline. The nursing instructor asks the student why the patient is receiving two antibiotics. What is the student nurse's best response? a) "This combination of medications will eradicate the infection faster than a single antibiotic." b) "Many people infected with gonorrhea are infected with chlamydia as well." c) "The combination of these two antibiotics reduces the risk of reinfection." d) "There are many resistant strains of gonorrhea, so more than one antibiotic may be required for successful treatment."

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? A. Midepigastric pain and pyrosis B. Diaphoresis and cool clammy skin C. Intermittent claudication and paloor D. Jugular vein distention and dependent edema

A 4-year-old child is admitted with a radial head subluxation, or "nursemaid's elbow." Which intervention should be taught to the caregivers to prevent such injury in the future? A. Avoiding picking up children from under the arms B. Avoiding swinging children by the hands C. Avoiding sports where swinging of the arms is required D. Not allowing children to play on the jungle gym

Following discharge teaching for a patient who has had a transurethral prostatectomy for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will increase fiber and fluids in my diet to prevent constipation." b. "I should call the doctor if I have any incontinence at home." c. "I will avoid heavy lifting or driving until I get approval from my health care provider." d. "I should continue to schedule yearly appointments for prostate exams."

In teaching a male patient to perform testicular self-examination, the nurse includes the information that a. the only structure normally felt in the scrotal sac is the testis. b. the examination should be done when the scrotum is warm. c. an appointment with the health care provider is needed if one testis is larger than the other. d. an examination should be performed whenever the patient showers or bathes.

Leuprolide (Lupron) and bicalutamide (Casodex) are prescribed for a patient with cancer of the prostate. In teaching the patient about these drugs, the nurse informs the patient that side effects may include a. low blood pressure. b. decreased sexual drive. c. urinary incontinence. d. frequent infections.

Max Thornton, a 24-year-old chef, is being seen by a physician at the urology group where you practice nursing. He has developed a painless ulcer on his penis and is rather concerned about his health. The urologist will be communicating his diagnosis of syphilis and prescribing treatment. What is the typical span of time between infection and developing symptoms with syphilis? a) 14 days b) 21 days c) 35 days d) 28 days

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication? a. It will help decrease the inflammation in the joints b. It improves tissue function and may decrease breakdown of cartilage c. It is a potent medication that decreases the client's joint pain d. It increases the production of synovial fluid in the joint

The client diagnosed with RA has developed swan-neck fingers. Which referral would be the most appropriate for the client? a. Physical therapy b. Occupational therapy c. Psychiatric counselor d. Home health nurse

The client diagnosed with RA who has been prescribed Plaquenil, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach? a. Explain that the less medication loses its efficacy after a few months b. Continue to have regular eye exams while taking the medication c. Have yearly MRIs to follow the progress d. Discuss that the drug is taken for 3 weeks and then stopped for a week

The client had been diagnosed to have chronic renal failure. He had undergone hemodialysis for the first time. What signs and symptoms when experienced by the client suggest that he is experiencing disequilibrium syndrome? a) restlessness, hypotension, headache b) nausea and vomiting, hypertension, dizziness c) lethargy, hypotension, dizziness d) thachycardia, hypotension, headache

The client is diagnosed with osteoarthritis. Which sign/symptom would the nurse expect the client to exhibit? a. Severe bone deformity b. Joint stiffness c. Waddling gait d. Swan neck fingers

The client is in end-stage renal failure (ESRD). Which of the following foods may be allowed for the client? a) banana b) apple c) carrot cake d) cantaloupe

The client is one day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? A. Medicate the client with intravenous morphine B. Assess the client's chest dressing and vital signs C. Encourage the client to turn from side to side D. Check the client's telemetry monitor

The client who has a history of gout also is diagnosed with urolithisis and the stones are determined to be of uric acid type. The nurse gives the client instructions in which foods to limit, including: a) milk b) liver c) apples d) carrots

The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action? a) check the sodium level b) place the client on a cardiac monitor c) encourage increased vegetables in the diet d) allow an extra 500 ml of fluid intake to dilute the electrolyte concentration

The client with chronic renal failure is undergoing peritoneal dialysis. He asks why the nurse monitors his blood glucose levels. Which of the following will be the most appropriate response by the nurse? a) I have to check if you have diabetes mellitus b) the dialysate contains glucose c) the procedure may lower your blood glucose levels d) it is a routine procedure for every client who undergoes the treatment

The doctor is considering whether to prescribe testosterone replacement therapy for a 62-year-old man who is concerned about a gradual decrease in sexual performance. Which information obtained by the nurse is most important to communicate to the doctor? a. The patient states that he has noticed a decrease in energy level for a few years. b. The patient has had a gradual decrease in the force of his urinary stream. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient's symptoms have increased steadily over the last few years.

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? A) Impaired transfer ability B) Risk for caregiver role strain C) Ineffective health maintenance D) Risk for unstable blood glucose level

The nurse has admitted a client who was brought to the hospital after a morphine overdose. What acid-base imbalance does the nurse expect to observe in this client? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved? A. An oral temperature of 98.8 F B. A urine specific gravity of 1.043 C. A urine output that is pale yellow D. A blood pressure of 120/80 mmHg

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

The nurse is creating a plan of care for the presurgical care of a client with a hip fracture. Which goal would be appropriate for the diagnosis of Tissue Perfusion: Peripheral, Ineffective? A. The client will report a lowered pain score after administration of pain medications. B. The client will maintain a distal pulse in the affected extremity. C. The client's open wound will remain free from signs of infection. D. The client will maintain core body temperature that is within normal limits.

The nurse is planning care for the client with Cushing's syndrome who has been admitted for complications related to the disease process. Which intervention should the nurse plan for this client to improve the impaired gas exchange? A) Monitor serum electrolytes. B) Schedule nursing activities to allow for periods of rest. C) Assess input and output accurately. D) Administer IV fluids per practitioner order.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires Nasogastric suction C. Has a history of Addison's disease D. Is taking a potassium-retaining diuretic

The nurse is teaching an older adult client on what they need to do if they are alone and sustain a fall. Which client statement indicates a need for additional teaching? A. "I should try to keep a cell phone with me at all times." B. "If I fall, I should not move because I can cause further injury." C. "I should ask a friend or family member to check in daily." D. I should participate in an emergency alert service such as Lifeline."

The nurse suspects a client with one functioning lung is developing chronic respiratory acidosis. Which manifestation did the nurse most likely assess in this client? A) Warm, flushed skin B) Daytime sleepiness C) Irritability D) Blurred vision

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? A) Help the UAP to insert the oral airway in the mouth. B) Tell the UAP to stop trying to insert anything in the mouth. C) Take no action because the UAP is handling the situation. D) Notify the charge nurse of the situation immediately.

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution."

Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome Prednisone is prescribed for Carlo. The nurse evaluate its effectiveness by a) checking his BP every 4 hours b) checking his urine for protein c) weighing him each morning before breakfast d) observing him for behavioral changes

Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome: At Carlo's last check-up when he was 2 1/2 years old, his BP was 95/60, PR was 110/min and weight was 15 kg. Which unexpected assessment today would the nurse report to help the diagnosis? a) BP: 95/60 b) weight: 20 kg c) PR: 110 d) temp: 37 C

Which client goal would be most appropriate for a client diagnosed with OA? a. Perform passive range-of-motion exercises b. Maintain optimal functional ability c. Client will walk three miles a day d. Client will join a health club

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

Which information would be most appropriate for a nurse to provide to a client who has never used a condom? a) A condom can be used, even if it is old, so long as the pack is unopened. b) A new condom should be used for each sex act. c) Cheap condoms of any brand can be used based on monetary constraints. d) A fresh condom should be unrolled over a limp penis before it becomes erect.

Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? A. Keep the client in the supine position with legs elevated B. Discuss a heart transplant, which is a definitive treatment C. Prepare the client for coronary artery bypass graft D. Teach the client to take a calcium channel blocker in the morning

Which medication is used off-label to reduce the occurrence of hot flashes associated with menopause? a Raloxifene (Evista) b Venlafaxine (Effexor) c Levothyroxine (Synthroid) d Triphenylethylene (Tamoxifen)

Which statement from the client regarding cast care requires additional teaching by the nurse? A. "I can use plastic shields around the cast while showering or bathing." B. "If the edges become rough and irritating, I can remove the rough edges." C. "I can apply ice to the cast and elevate my arm to prevent swelling." D. "I should never place objects in the cast to relieve itching."

Which statement is correct regarding traction? A. Traction weights should rest either on the bed or on the floor. B. Skeletal traction may be used in conjunction with skin traction. C. Skin traction is contraindicated in older adults with frail skin. D. Skin traction is used when skeletal traction is contraindicated.

Within the free clinic where you practice nursing, you hold weekly sexual education classes open to the public. Within the classroom, you communicate the CDC's numbers for the incidence of STIs and their impact upon public health. Which is the fastest-spreading bacterial STI in the United States? a) Gonorrhea b) Chlamydia c) Herpes simplex 1 d) HPV

The nurse is preparing to analyze a client's arterial blood gas results. List the steps in the order that the nurse should follow when analyzing this laboratory test. A) Look at the PaCO2. B) Look at the pH. C) Evaluate the relationship between pH and PaCO2. D) Look for compensation. E) Evaluate the pH, HCO3, and base excess for a possible metabolic problem. F) Look at the bicarbonate. G) Evaluate oxygenation.

B, A, C, F, E, D, G

The nurse is preparing to instruct a client with type 1 diabetes mellitus on the mechanism behind the development of ketoacidosis. List the order in which the nurse should provide this information. A) Production of lactate and hydrogen ions B) Development of lactic acidosis C) Breakdown of fatty tissue D) Reduction in intracellular glucose E) Fatty acids converted to ketones

B, A, D, C, E

A client with pneumonia develops respiratory acidosis. Which medications should the nurse prepare to administer to this client? (Select all that apply) A) Furosemide (Lasix) 20 mg by mouth twice a day B) Amoxicillin 1 gram intravenous every 6 hours C) Albuterol inhaler 2 puffs every 4 hours D) Diazepam (Valium) 2 mg by mouth at bedtime for sleep E) Potassium chloride 20 mEq in 100 mL 0.9% normal saline intravenous every day

B, C

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement first? (Select All that Apply) A. Administer morphine sulfate Intramuscularly B. Administer an aspirin orall C. Apply oxygen via nasal cannula D. Place the client in a supine position E. Administer nitroglycerin subcutaneously

B, C

The nurse is caring for a client with metabolic acidosis. Which of the following are appropriate goals for this client? (Select all that apply.) A) The client will maintain a respiratory rate of 30 or more. B) The client will describe preventative measure for the underlying chronic illness. C) The client will maintain baseline cardiac rhythm. D) pH will range from 7.25 to 7.35. E) The client will take potassium supplements to increase potassium levels.

B, C

The nurse is preparing to examine a client who is experiencing menopause. What information should the nurse obtain when performing a health history? (Select all that apply.) a Posture b Menstrual history c Medications d Sleep pattern e Vital signs

B, C, D

The nurse is teaching older women about health risks for the postmenopausal period and would include which as health risks? (Select all that apply.) a Joint degeneration b Macular degeneration c Breast cancer d Cognitive changes e Gout

B, C, D

Which client should the nurse identify to be at a greater risk of fractures while reviewing their health records? (Select all that apply.) A. The client with leukemia B. The client with bone neoplasms C. The client who is malnourished D. The client with osteoporosis E. The client with hypercalcemia

B, C, D

The nurse is explaining the use of a splint for an ulnar fracture. Which information should be included? (Select all that apply.) A. At greater risk for compartment syndrome B. May be used as a temporary measure until a cast can be applied C. Easily removed if needed D. Can be adjusted if swelling occurs E. Allows some movement of the joint

B, C, D, E

The nurse is providing education to a client who has been diagnosed with menopause. Which health promotion intervention should the nurse discuss with the client? (Select all that apply.) a Wearing tight clothing b Eating a balanced diet that includes fruits, vegetables, and high-fiber foods c Doing Kegel exercises d Avoiding alcohol and cigarette use e Participating in yoga classes

B, C, D, E

Which treatment is considered an alternative or complementary therapy in managing a menopausal client? (Select all that apply.) a Hormone replacement therapy b Herbs c Yoga d Bioidentical hormones e Massage

B, C, D, E

The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? (Select All that Apply) A. Obtain a midstream urine specimen B. Attach telemetry monitor to the client C. Start a saline lock in the right arm D. Draw a baseline metabolic panel (BMP) E. Request an order for a STAT 12-lead ECG

B, C, E

The nurse who is caring for a client who has a fractured pelvis has determined that the client is experiencing acute pain. Which intervention should the nurse implement? (Select all that apply.) A. Maintaining strict bedrest until the bone is fused B. Elevating the affected extremity on a pillow C. Playing the client's favorite music D. Applying a hot pack to the site of the injury E. Supporting the extremity above and below the fracture site when moving

B, C, E

A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings should the nurse suspect will confirm this diagnosis? (Select all that apply.) A) Serum glucose level 142 mg/dL B) Blood pH 7.47 and bicarbonate 34 mEq/L C) Intravenous pyelogram shows kidney stones D) Bilateral lower lobe infiltrates noted on chest x-ray E) Electrocardiogram changes consistent with hypokalemia

B, E

Which statement concerning bone fractures is correct? (Select all that apply.) A. "Bone fractures do not result from low bone density." B. "Bone fractures may result from repetitive forces or twisting." C. "A bone fracture can be the direct result of excess pressure in the fibrous membrane or fascia." D. "Diseases such as neoplasms do not cause bone fractures." E."The severity of a bone fracture depends on the force of the action against the bone and bone strength."

B, E

A 22-year-old man tells the nurse at the health clinic that he has recently become unable to achieve an erection. When assessing for possible etiologic factors, which question should the nurse ask first? a. "Have you been experiencing an unusual amount of stress?" b. "Do you have any history of an erection that lasted for 6 hours or more?" c. "Are you using any recreational drugs or drinking a lot of alcohol?" d. "Do you have any chronic diseases, such as diabetes mellitus?"

A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. The nurse explains that a. riding a bicycle raises prostate specific antigen levels and may increase BPH risk. b. prevention is not possible because prostatic enlargement occurs with normal aging. c. decreasing butter and margarine and increasing fruits in the diet may help. d. taking a daily vitamin E supplement has reduced prostate size in some men.

A 45-year-old waitress with a history of IV drug use also is HIV-positive. She has been following her antiretroviral medication regimen faithfully and is doing well. She's attending college to get a social work degree and is focused on a bright future. In her regular CD counts, what factor will indicate she has progressed from HIV to AIDS? a) CD count > 200/mm b) CD count > 100/mm c) CD count < 200/mm d) CD count < 100/mm

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

A 53-year-old woman asks the nurse if there are any definitive laboratory tests that would show that she has entered menopause. The nurse responds that which test is done to clarify the diagnosis? a Complete blood count b Blood, urea, nitrogen (BUN) levels c Follicle-stimulating hormone (FSH) level d Estrogen levels

A 64-year-old man undergoes a perineal radical prostatectomy for stage C prostatic cancer. Postoperatively, the nurse establishes the nursing diagnosis of risk for infection related to a. urinary stasis. b. urinary incontinence. c. possible fecal contamination of the surgical wound. d. placement of a suprapubic catheter into the bladder.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

A adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? a) 0.2 mg/dlL b) 0.5 mg/dL c) 1.9 mg/dL d) 3.5 mg/dL

A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets this as which of the following? A) Metabolic acidosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic alkalosis

A client brought to the Emergency Department for treatment of an overdose has arterial blood gas results that indicate acute respiratory acidosis. For which substance should the nurse plan care for this client? A) Cocaine B) Marijuana C) Oxycodone D) PCP

A client has been diagnosed to have chronic renal failure. Sodium polysterene sulfonate (exchange resin kayexalate) is prescribed. The action of the medication is that it releases a) bicarbonate in exchange for primarily sodium ions b) sodium ions in exchange for primarily bicarbonate ions c) sodium ions in exchange for primarily potassium ions d) potassium ions in exchange for primarily sodium ions

A client is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas value should the nurse expect with respiratory alkalosis? A) pH is 7.33 and PaCO2 is 36. B) pH is 7.30 and HCO3 is 30. C) pH is 7.47 and PaCO2 is 25. D) pH is 7.35 and PaO2 is 88.

A client is diagnosed as being in the primary stage of syphilis? Which of the following would the nurse expect as a finding? a) Development of gummas b) Palmar rash c) Genital chancres d) Development of central nervous system lesions

A client is prescribed didanosine (Videx) as part of his highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? a) "You should take the drug with an antacid." b) "It doesn't matter if you take this drug with or without food." c) "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." d) "When you take this drug, eat a high-fat meal immediately afterwards."

A client visits the nurse complaining of diarrhea every time they eat. The client has AIDS and wants to know what they can do to stop having diarrhea. What should the nurse advise? a) Reduce food intake. b) Encourage large, high-fat meals. c) Avoid residue, lactose, fat, and caffeine. d) Increase the intake of iron and zinc.

A client who has a renal mass asks the nurse why an ultrasound has been scheduled, as opposed to other diagnostic tests that may be ordered. The nurse formulates a response based on the understanding that: a) all other tests are more invasive than an ultrasound b) all other tests require more elaborate postprocedure care c) an ultrasound can differentiate a solid mass from a fluid-filled cyst d) an ultrasound is much more cost effective than other diagnostic tests

A client with genital herpes asks the nurse about what to expect with the infection. Which of the following responses would be most appropriate? a) Once you take the medication, the infection will be gone for good. b) You might have to try several different medications before finding one that works. c) Even though you don't have symptoms, you could still spread the infection. d) You can expect other outbreaks, each of which will be longer than the first.

A female college student is distressed at the recent appearance of genital warts, an assessment finding that her care provider has confirmed as attributable to human papillomavirus (HPV) infection. Which of the following information should the nurse give the patient? a) "It's important to start treatment soon, so you will be prescribed pills today." b) "I'd like to give you an HPV vaccination if that's okay with you." c) "There is a chance that these will clear up on their own without any treatment." d) "Unfortunately, this is going to greatly increase your chance of developing pelvic inflammatory disease."

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

A mother brings her young child to the clinic for an evaluation of an infection. The mother states, "He's been taking antibiotics now for more than 2 months and still doesn't seem any better. It's like he's always sick." During the history and physical examination, which of the following would alert the nurse to suspect a primary immunodeficiency? a) Superficial wound on the child's left leg b) History of fungal diaper rash c) Ten ear infections in the past year d) Weight within age-appropriate parameters

A nurse is assessing a client who is diagnosed with cystitis. Which assessment finding is inconsistent with the typical clinical manifestations noted in this disorder? a) hematuria b) low back pain c) urinary retention d) burning on urination

A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? A. Tetany B. Tremors C. Areflexia D. Muscular excitability

A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT? A. Tap water B. Sterile Water C. 0.9% Sodium Chloride D. 0.45% Sodium Chloride

A nurse is teaching a community health class of women and explains that a sexually transmitted infection (STI) is associated with an increased risk of infertility in women. Which of the following STIs would the nurse identify? a) Herpes simplex b) Syphilis c) Chlamydia d) Gonorrhea

A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an elevated PSA level. The nurse will anticipate that the patient will need teaching about a. uroflometry studies. b. cystourethroscopy. c. transrectal ultrasonography (TRUS). d. magnetic resonance imaging (MRI).

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about? a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? A. Renal calculi B. Renal trauma C. Recent sore throat D. Family history of acute glomerulonephritis

Clinical manifestations of acute glomerulonephritis include which of the following? A. Chills and flank pain B. Oliguria and generalized edema C. Hematuria and proteinuria D. Dysuria and hypotension

Diagnosis of acute pyelonephritis has been established your nursing intervention includes the following except: a) provide health teaching and discharge planning b) administer antibiotic c) measure I and O d) provide adequate comfort and rest

During a home visit, the nurse evaluates care provided to a client with type 1 diabetes mellitus and a history of metabolic acidosis. Which outcome indicates that the care of this client has been successful? A) The client is injecting insulin into thigh muscle. B) The client is taking laxatives three times a week to ensure adequate bowel movements. C) The client is eating three balanced meals per day with two snacks. D) The client is taking aspirin 325 mg every 6 hours to treat arthritis pain.

During a home visit, the nurse evaluates teaching provided to a client recently hospitalized for metabolic alkalosis. Which observation indicates that additional teaching is required? A) Drinks 2 cups of black coffee each day. B) Consumes one orange each day with breakfast. C) Ingests bicarbonate of soda after each meal. D) Monitors and tracks daily weights.

During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern? A) Daily ingestion of a banana with breakfast B) Daily weight consistent C) Daily use of sodium bicarbonate for gastric upset D) Daily use of prescribed NSAIDs for arthritic pain

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

During the examination portion of her annual checkup, a 55-year-old client has several new complaints. Which subjective symptoms of menopause would the nurse expect to find during data collection? a Hair growth on the upper lip b Decreased skin elasticity c Night sweats d Rise in vaginal Ph

Screening for chlamydia is recommended for young women because A) Chlamydia is frequently comorbid with HIV. B) Chlamydial infections may progress to sepsis. C) Untreated chlamydial infections can lead to infertility. D) Chlamydial infections are treatable only in the early stages of infection.

Situation: Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome. The diagnosis of Idiopathic Nephrotic Syndrome has been confirmed. Which unexpected finding would the nurse report? a) proteinuria b) distended abdomen c) blood in the urine d) elevated serum lipid levels

The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of: a) pyelonephritis b) glomerulonephritis c) trauma to the bladder or abdomen d) renal cancer in the client's family

The client diagnosed with OA is a resident in a long term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed nursing assistant? a) Allow the client to stay in bed until the pain becomes bearable b) Tell the assistant to give the client a bed bath this morning c) Try to encourage the client to get up and go to the shower d) Notify the family that the client is refusing to be bathed

The client diagnosed with RA is receiving care through a nurse practitioner clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits? a. Perform joint x-rays to determine progression of the disease b. Send blood to the lab for an erythrocyte sedimentation rate (ESR) c. Recommend the flu and pneumonia vaccines d. Assess the client for increasing joint involvement

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel is encouraging the client to move the legs. Which action should the nurse implement? A. Instruct the UAP to stop encouraging leg movements B. Report this behavior to the charge nurse as soon as possible C. Praise the UAP for encouraging the client to move legs D. Take no action concerning the UAP's behavior

The client diagnosed with a myocardial infarction is six hours post-right femoral percutanous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? A. The client is keeping the affected extremity straight B. The pressure dressing to the right femoral area is intact C. The client is complaining of numbness in the right foot D. The client's right pedal pulse is +3 and bounding

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? A. Administer sublingual nitroglycerin B. Obtain a stat 12 Lead ECG C. Have the client sit down immediately D. Assess the client's vital signs

The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which of the following characteristics? A) Gastric secretions are green in color. B) Gastric secretions are alkaline. C) Gastric secretions are acidic. D) Gastric secretions have a foul smell.

The client has just returned from a cardiac catherization. Which assessment data would warrant immediate intervention from the nurse? A. The client's BP is 110/70 and pulse is 90 B. The client's groin dressing is dry and intact C. The client refuses to keep the leg straight D. The client denies any numbness and tingling

The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection? a) increased urinary output, BUN = 15 mg/dL b) HCT = 50%, Hgb = 17 g/dl c) decreased urinary output, sudden weight gain d) decreased urinary output, sudden weight loss

The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? A) Assess the client's neurological status every hour. B) Monitor the client's heart rhythm via telemetry. C) Administer an anticonvulsant medication by intravenous push. D) Prepare to administer a glucocorticosteroid orally.

The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests would the nurse expect the HCP to order to R/O OA? a. Full body MRI scan b. Serum studies for synovial fluid amount c. X-ray of the affected joints d. Serum erythrocyte sedimentation rate (ESR)

The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the client to be lethargic, confused, and breathing rapidly. What is the nurse's priority response to the situation? A) Stop the infusion and notify the physician because the client is in alkalosis. B) Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis. C) Continue the infusion, because the client is still in acidosis, and notify the physician. D) Increase the rate of the infusion and continue to assess the client for symptoms of acidosis.

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which pre-procedure teaching should the nurse implement? A) Tell the client to take any routine antiseizure medication prior to the EEG. B) Tell the client not to eat anything for eight (8) hours prior to the procedure. C) Instruct the client to stay awake for 24 hours prior to the EEG. D) Explain to the client that there will be some discomfort during the procedure.

The client is seen in the Emergency Department with symptoms of a panic attack, including hyperventilation. The nurse suspects that the client may be at risk for which health problem on admission? A) Hypo-ventilation B) Vomiting C) Respiratory alkalosis D) Memory loss

The client who has had a myocardial infarction is admitted to the telementry unit from intensive care. Which referral would be most appropriate for the client? A. Social worker B. Physical therapy C. Cardiac rehabilitation D. Occupation therapy

The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? A) Perform a complete neurological assessment. B) Awaken the client every 30 minutes. C) Turn the client to the side and allow the client to sleep. D) Interview the client to find out what caused the seizure.

The home care nurse is making follow-up visits to a client following renal transplant. The nurse assesses the client for which signs of acute graft rejection? a) hypotension, graft tenderness, and anemia b) hypertension, oliguria, thirst, and hypothermia c) fever, hypertension, graft tenderness, and malaise d) fever, vomiting, hypotension, and copious amounts of dilute urine

The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? A) Alzheimer's disease. B) Parkinson's disease. C) Cerebral vascular accident (stroke). D) Brain atrophy due to aging.

The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the best understands the information if the client states to record daily the: a) amount of activity b) pulse and respiratory rate c) intake and output and weight d) blood urea nitrogen and creatinine levels

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates a complementary form of treatment for OA? a. "I take medication every two hours for my pain" b. "I use a heating pad when I go to bed at night" c. "I wear a copper bracelet to help with my OA" d. "I always wear my ankle splints when I sleep"

The nurse is caring for a client who has been admitted to the unit with respiratory failure and respiratory acidosis. What data from the nursing history would the nurse suspect contributed to the client's current state of health? A) Use of ibuprofen for the control of pain B) A recent trip to South America C) Aspiration pneumonia D) Recent recovery from a cold virus

The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals a pH of 7.20 and a PaCO2 of 49 mmHg. Which change in ventilator settings should the nurse anticipate? A) Increase in humidification of inspired air B) Decrease of FiO2 from 30% to 25% C) Increased respiratory rate to 30 breaths per minute D) Decreased tidal volume of each breath

The nurse is caring for a client with an endometrial implant. The client asks the nurse what happens to the implant now that she is experiencing menopause. The best reply by the nurse is that the implant: a tends to become malignant. b enlarges in size. c tends to atrophy and disappear. d increases in numbers.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased Urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight Loss B. Flat neck and Hand veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)

The nurse is caring for a comatose client with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this client? A) Measuring vital signs B) Measuring intake and output C) The client's recent eating behaviors D) Identifying current oxygen saturation level

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

The nurse is caring for clients on a medical floor. Which client should the nurse assess first? a. The client diagnosed with RA who is complaining of pain at a "3" on a 1-10 scale b. The client diagnosed with Systemic Lupus Erythematosus who has a rash across the bridge of the nose c. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV d. The client diagnosed with scleroderma who has hard, waxylike skin near the eyes

The nurse is caring for the client with a history of anxiety who is experiencing chest pain, palpitations and dyspnea. Which intervention would be a priority for this client? A) Providing educational material for the client's medical diagnosis B) Ordering a regular diet for the client C) Reassuring the client that symptoms will resolve D) Asking Respiratory Therapy to set up a mechanical ventilator

The nurse is gathering data from a male client who is suspected of having gonorrhea. Which of the following would the nurse most likely find? a) Testicular pain b) Purulent rectal discharge c) Pain on urination d) Skin rash

The nurse is instructing a client with a history of acidosis on the use of sodium bicarbonate. Which client statement indicates that additional teaching is needed? A) "I should contact the doctor if I have any gastric discomfort with chest pain." B) "I need to purchase antacids without salt." C) "I should use the antacid for at least 2 months." D) "I should call the doctor if I get short of breath or start to sweat with this medication."

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? A. Bradycardia B. Elevated blood pressure C. Changes in mental status D. Bilateral crackles in the lung

The nurse is planning care for an older client with respiratory acidosis. Which intervention should the nurse include in this client's plan of care? A) Administer prescribed intravenous fluids carefully. B) Administer intravenous sodium bicarbonate. C) Maintain adequate hydration. D) Reduce environmental stimuli.

The nurse is preparing to discharge a client with congestive heart failure on furosemide (Lasix). The nurse determines that teaching has been effective if the client makes which statement? A) "I will use only sodium bicarbonate as my antacid." B) "I will restrict my intake of fluids." C) "I will use potassium supplements while I am taking Lasix." D) "I will take antacids only for my gastric discomforts."

The nurse is providing discharge teaching to the family of an older adult client who was treated for a fracture after a fall. Which recommendation should the nurse include in the teaching? A. Always wear socks when ambulating. B. Use a step stool when possible. C. Start a mild exercise program. D. Remove the rubber mat from tub.

The nurse is teaching a woman about the hormonal changes that occur during menopause. Which hormonal change would the nurse state is responsible for the symptoms of menopause? a Decreased follicle-stimulating hormone b Decreased progesterone c Decreased estrogen d Decreased luteinizing hormone

The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-bases imbalance: A) Metabolic Acidosis B) Metabolic Alkalosis C) Respiratory Acidosis D) Respiratory Alkalosis

The nurse will teach the patient with chronic bacterial prostatitis that a. PSA elevation indicates that he has concurrent prostate cancer. b. Nonsteroidal antiinflammatory drugs (NSAIDs) usually provide adequate pain control. c. sexual intercourse and masturbation will relieve symptoms. d. antibiotics should be taken for 7 to 10 days.

The physical assessment and history of a 29-year-old female patient are indicative of human papillomavirus (HPV) infection. You would perform patient teaching related to A) Gardasil. B) Antibiotic therapy. C) Wart removal options. D) Treatment with antiviral drugs.

Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome. Carlo's potential for impairment of skin integrity is related to: a) joint inflammation b) drug therapy c) edema d) generalized body rash

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of a. testicular torsion. b. STD infection. c. undescended testicles. d. testicular trauma.

When performing discharge teaching for a patient who has undergone a vasectomy in the health care provider's office, the nurse instructs the patient that a. he may have temporary erectile dysfunction (ED) because of postoperative swelling. b. he should not have sexual intercourse until his 6-week follow-up visit. c. he should continue the use of other methods of birth control for 6 weeks. d. he will notice a decrease in the appearance and volume of his ejaculate.

When planning care for a client, which nursing diagnosis addresses a physical concern associated with menopause? a Risk of low self-esteem b Impaired mood c Potential for urinary dysfunction d Negative body image

Which client is least likely to be at risk for the development of third spacing? A. The client with cirrhosis B. The client with liver failure C. The client with diabetes mellitus D. The client with chronic kidney disease

Which client problem is priority for a client diagnosed with RA? a. Activity intolerance b. Fluid and Electrolyte balance c. Alteration in comfort d. Excessive nutritional intake

Which client would most likely be misdiagnosed for having a myocardial infarction? A. A 55 year old Caucasian male with crushing chest pain and diaphoresis B. A 60 year old Native American male with an elevated troponin level C. A 40 year old HiDpanic female with a normal ECG D. An 80 year old Peruvian female with normal CK-MB at 12 hours

Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient? A. Dysuria, frequency, and urgency B. Back pain, nausea, and vomiting C. Hypertension, oliguria, and fatigue D. Fever, chills, and right upper quadrant pain radiating to the back

Which member of the health care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub? a. Physiatrist b. Social worker c. Physical therapist d. Counselor

Which of the following complaints is common in a client with pyelonephritis? a) right upper quadrant pain b) left upper quadrant pain c) pain at the costovertebral region d) pain at the suprapubic region

Which preprocedure information should be taught to the female client having an exercise stress test in the morning? A. Wear open-toed shoes to the stress test B. Inform the client not to wear a bra C. Do not eat anything for 4 hours D. Take the beta blocker one hour before the test

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? A) "It is all right for me to drink coffee for breakfast." B) "My menstrual cycle will not affect my seizure disorder." C) "I am going to take a class in stress management." D) "I should wear dark glasses when I am out in the sun."

Which statement by the nurse describes a comminuted fracture to the client? A. The ends of the broken bones are forced together." B. The bone is breaking through the skin." C. The bone is broken into many pieces." D. A fragment of the bone is separated from the rest of the bone."

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

While reviewing laboratory results, the nurse notes that a client's potassium level is 2.8 mEq/L and chloride level is 100 mEq/L. How should the nurse plan to support this client's acid-base balance? A) Prepare to administer 0.9% sodium chloride infusion. B) Measure for nasogastric tube insertion. C) Discuss potassium chloride replace therapy with the healthcare provider. D) Review implications of transfusing with ammonia chloride.

An Asian-American adolescent is hospitalized following several days of vomiting following food poisoning. The nurse is planning to include which points when teaching the client's family at discharge? (Select all that apply.) A) Immunizations for the adolescent B) Nutritional patterns of the adolescent C) Signs and symptoms of metabolic alkalosis D) Proper food-handling techniques E) Normal laboratory values of the adolescent

C, D

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? A) Obtain computed tomography (CT) scan without contrast. B) Infuse tissue plasminogen activator (tPA). C) Administer oxygen to keep O2 saturation >95%. D) Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B

A woman experiencing perimenopausal symptoms asks the nurse what she can do to help control the symptoms. What interventions should the nurse recommend? (Select all that apply.) a Increase caffeine intake b Avoid sexual intercourse c Start a regular exercise routine d Dress in layers e Keep the bedroom cool

C, D, E

The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis? (Select all that apply.) A) Apply wrist restraints and secure to the bed frame. B) Discuss chemical restraint use with the healthcare provider. C) Keep the bed in the lowest position. D) Keep bed side rails raised. E) Place a clock and calendar at the bedside.

C, D, E

The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? (Select all that apply.) A) Ineffective Health Maintenance B) Risk for Hypothermia C) Deficient Fluid Volume D) Risk for Impaired Gas Exchange E) Risk for Injury

C, D, E

The nurse is reviewing new orders written for a client experiencing respiratory alkalosis. Which orders would be appropriate for this client's care needs? (Select all that apply) A) Oxygen 2 liters via face mask B) Restrict fluids to 2 liters per day. C) Admit to a private room. D) Infuse 1 ampule of sodium bicarbonate now. E) Draw arterial blood gases.

C, E

A 16-year-old patient comes to the free clinic and is diagnosed with primary syphilis. The patient states that she contracted this disease by holding hands with someone who has syphilis. What is the most appropriate nursing diagnosis for this patient? a) Alteration in comfort related to impaired skin integrity b) Fear related to complications c) Noncompliance with treatment regimen related to age d) Knowledge deficit related to modes of transmission

A 30-year-old female patient has sought care because of the recent appearance of itchy lesions on her vulva, some of which have recently burst. The patient's description of her problem would lead you to first suspect A) HIV. B) Gonorrhea. C) Chlamydia. D) Genital herpes.

A 46-year-old man has had erectile dysfunction (ED) for about 3 years when he finally seeks help for the problem. He tells the nurse that he decided to seek help because his wife "is losing patience with the situation." The most appropriate nursing diagnosis for the patient is a. risk for anxiety related to inability to perform sexually. b. situational low self-esteem related to loss of satisfying sexual activity. c. ineffective sexuality patterns related to ED. d. ineffective role performance related to effects of ED.

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safely? a) take blood pressures only on the right arm to ensure accuracy b) use the fistula for all venipunctures and intravenous infusions c) ensure that small clamps are attached to the AV fistula dressing d) assess the fistula for the presence of a bruit and thrill every 4 hours

A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse first asks the client about a recent history of: a) bleeding ulcer b) deep vein thrombosis c) myocardial infarction d) streptococcal infection

A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is: a) dull and aching in the costovetebal area b) aching and camplike thoughout the abdomen c) sharp and radiating posteriorly to the spinal column d) excruciating, wavelike, and radiating toward the genitalia

A client is diagnosed as being in the primary stage of syphilis? Which of the following would the nurse expect as a finding? a) Palmar rash b) Development of gummas c) Development of central nervous system lesions d) Genital chancres

A client is diagnosed as perimenopausal. Which psychological manifestation is the client most likely experiencing? a Increased vaginal pH b Decreased skin elasticity c Irritability d Fatigue

A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. As an essential preprocedure component of the nursing assessment, the nurse plans to ask the client about a history of: a) familial renal disease b) frequent antibiotic use c) long-term diuretic therapy d) allergy to shellfish or iodine

A client who is found unresponsive has arterial blood gases drawn and the results indicate dthe following: pH is 7.12, Pco2 is 90, and HCO3- is 22. the nurse interprets the results as indicating which condition? A) Metabolic Acidosis with compensation B) Respiratory Acidosis with compensation C) Metabolic Acidosis without compensation D) Respiratory Acidosis without compensation

A client who is post menopausal with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which statement by the nurse provides the client with accurate information? A) The progesterone will help prevent cervical cancer B) The progesterone will help prevent breast cancer C) The progesterone will help prevent liver disease D) The progesterone will help prevent endometrial cancer

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypo-ventilating and has a respiratory rate of 10 breaths/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? A) A decreased pH and an increased CO2 B) An increased pH and a decreased Co2 C) A decreased pH and a decreased HCO3- D) An increased pH with an increased HCO3-

A client with genital herpes simplex infection asks the nurse, "Will I ever be cured of this infection?" Which response by the nurse would be most appropriate? a) "All you need is a dose of penicillin and the infection will be gone." b) "There is a new vaccine available that prevents the infection from returning." c) "Once you have the infection, you develop an immunity to it." d) "There is no cure, but drug therapy helps to reduce symptoms and recurrences."

A nurse is assisting with a physical examination of a male client. Which of the following signs and symptoms is most clearly suggestive of primary genital herpes? a) Emergence of hard, painless nodules on the shaft of the penis b) Presence of purulent, whitish discharge from the penis c) Production of cloudy, foul-smelling urine d) Itching, pain, and the emergence of pustules on the penis

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? A. Tetany B. Twitches C. Positive Trousseau's sign D. Loss of deep tendon reflexes

A nurse is caring for a client with diabetic ketoacidosis and documents the the client is experiencing Kussmaul's respiration's. Based on this documentation, which of the following did the nurse observe? A) Respiration's that cease for several seconds B) Respiration's that are regular but abnormally slow C) Respiration's that are labored and increased in depth and rate D) Respiration's that are abnormally deep, regular, and increased in rate

A nurse is providing care to a client with chlamydia. The nurse anticipates that the client will also receive treatment for which of the following? a) Mycoplasma b) Trichomoniasis c) Human papillomavirus d) Gonorrhea

A nurse is teaching a client with genital herpes. Education for this client should include an explanation of: a) why the disease is transmittable only when visible lesions are present. b) the need for the use of petroleum products. c) the option of disregarding safer-sex practices now that he's already infected. d) the importance of informing his partners of the disease.

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

A patient comes to the free clinic complaining of urethral discharge. On assessment, the nurse notes that the patient is feverish. During the assessment, the patient admits to having unprotected sex. The nurse suspects the patient may have a diagnosis of what? a) HIV b) Chlamydia c) Syphilis d) Gonorrhea

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to a. administer the ordered IV morphine sulfate, 4 mg. b. increase the flow rate of the continuous bladder irrigation. c. give the ordered the belladonna and opium suppository. d. manually instill 50 ml of saline and try to remove the clots.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soap solution enemas until clear to a client. The UAP reports that three enemas have been administered and that the client is still passing brown liquid stool. What should the RN instruct the UAP to do? A. Administer a Fleet Enema B. Administer an oil retention enema C. Wait 30 minutes and then administer another enema D. Stop administering the enemas until the health care provider is notified

After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client states which of the following? a) "I will clean my kitchen counter with hot water." b) "Alcohol is good to clean any skin areas that are dry or chafed." c) "I should avoid eating cooked fruits and vegetables." d) "I should avoid being around other people who have an infection."

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment? a) Syphillis b) Gonorrhea c) Chlamydia d) Genital herpes

A 34-year-old client presents to the family practice clinic with complaints of not having a menstrual period in the past 14 months. What data should the nurse obtain when performing a physical examination on the client? a Drug and alcohol use b Sexual history c Menstrual history d Weight and height

In the oliguric phase of renal failure, what is the most appropriate nursing diagnosis? a) fluid volume deficit b) activity intolerance c) ineffective breathing pattern d) fluid volume excess

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

The client diagnosed with OA is prescribed a NSAID. Which instruction should the nurse teach the client? a. Take the medication on an empty stomach b. Make sure the client tapers the medication when discontinuing c. Apply the medication topically over the affected joints d. Notify the HCP if vomiting blood

The client has been diagnosed with OA for the last 7 years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem would the nurse identify? a. Severe pain b. Body-image disturbance c. Knowledge deficit d. Depression

The client is 3 hours post myocardial infarction. Which data would warrant immediate intervention by the nurse? A. Bilateral peripheral pulses 2+ B. The pulse oximeter reading is 96% C. The urine output is 240 mL in the last 4 hours D. Cool, clammy, diaphoretic skin

The client recently diagnosed with RA is prescribed aspirin, an NSAID medication. Which comment by the client would warrant immediate intervention by the nurse a. "I always take the aspirin with food" b. "If I have dark stools, I will call my HCP" c. "Aspirin will not cure my arthritis" d. "I am having some ringing in my ears"

The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: a) check the shunt for the presence of bruit and thrill b) observe the site once as time permits during the shift c) check the results of the prothrombin time as they are determined d) ensure that small clamps are attached to the arteriovenous shunt dressing

The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a) during dialysis b) just before dialysis c) the day after dialysis d) on return form dialysis

The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instructions should the nurse teach regarding the use of NSAIDs? a. Take an over-the-counter medication for the stomach b. Drink a full glass of water with each pill c. If a dose is missed, double the medication at the next dosing time d. Avoid taking the NSAID on an empty stomach

The health care provider orders a blood test for prostate-specific antigen (PSA) when an enlarged prostate is palpated during a routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the test, the nurse's response is based on the knowledge that a. elevated levels of PSA are indicative of metastatic cancer of the prostate. b. PSA testing is the "gold standard" for making a diagnosis of prostate cancer. c. baseline PSA levels are necessary to determine whether treatment is effective. d. PSA levels are usually elevated in patients with cancer of the prostate.

The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? A) Push aside any furniture. B) Place the client on his side. C) Assess the client's vital signs. D) Ease the client to the floor.

The mother of a 1-month-old infant calls the nurse who works in the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. The nurse knows that this infant is at risk for metabolic acidosis. Which of the following is the priority nursing action? A) Instruct the mother to provide the infant with 50 mL of glucose water. B) Instruct the mother to measure the infant's urine output for 24 hours. C) Instruct the mother to give the infant at least 2 ounces of juice every 2 hours. D) Instruct the mother to bring the infant to the clinic for evaluation.

The nurse concludes that a client has understood teaching about menopause when the client states the following: a "I have missed two periods now and am grateful I will have no more." b "I will experience symptoms of menopause for 2 weeks." c "I am depressed about having this disease." d "I know I have begun menopause and it will take a while to finish."

The nurse develops a post-procedure plan of care for a client who had a renal biopsy. The nurse avoids documenting which intervention in the plan? a) administering analgesics as needed b) encouraging fluids to at least 3L in the first 24 hours c) testing serial urine samples with dipstick for occult blood d) ambulating the client in the room and hall for short distances

The nurse instructs a client with a history of acute respiratory acidosis and lung infections on ways to prevent further episodes of the health problem. Which client statement indicates that teaching has been effective? A) "I will limit drinking alcohol to the evening hours only." B) "I will limit my intake of bananas and oranges." C) "I will take prescribed antibiotics until my symptoms subside." D) "I will receive the annual influenza vaccination."

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? A. The client's apical pulse is 64 B. The client's calcium level is elevated C. The client's telemetry shows occasional PVCs D. The client's blood pressure is 90/62

The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention? a. The client complains of joint stiffness and the knees feel warm to the touch b. The client has experienced one kg weight loss and is very tired c. The client requires a heating pad applied to the hips and back to sleep d. The client is crying, has a flat facial affect, and refuses to speak to the nurse

The nurse is discussing open reduction and internal fixation with a client who is considering surgery to correct a bone fracture. Which statement by the nurse is correct? A. "Internal fixation is performed when soft tissue damage prevents external fixation." B. "A longer hospital stay will be required." C. "A metal bar will be placed outside the skin to stabilize the bone." D. "Internal fixation allows earlier return to full function."

The nurse is interviewing Melinda Britt during her annual gynecologic exam. Which statement by Melinda would cause you to believe she is experiencing perimenopause? a "I am so cold lately." b "I feel that my appetite is really increasing." c "I have problems with constipation." d "I often experience sweating at night."

The nurse is providing home care instructions to a client experiencing menopause. Which activity will assist in managing mood swings? a Doing Kegel exercises b Keeping the bedroom cool c Avoiding cigarettes d Performing deep breathing exercises

The nurse is reviewing orders written by the healthcare provider for a client with metabolic acidosis. Which order should the nurse question before implementing it for the client? A) Begin intravenous infusion of 0.9% normal saline. B) Draw serum potassium levels every 2 hours. C) Draw arterial blood gas samples every 2 hours. D) Administer 1 ampule of sodium bicarbonate now.

The nurse is reviewing orders written for a client with chronic respiratory acidosis. Which order should the nurse question before implementing for this client? A) Keep head of the bed elevated to 40-degree angle. B) Dextrose 5% and 0.45% normal saline at 100 mL per hour C) Consult Respiratory Therapy for breathing treatments four times a day. D) Oxygen 4 liters per nasal cannula

The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A) pH 7.32 B) PaCO2 18 mmHg C) HCO3 8 mEq/L D) PaCO2 48 mmHg

The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the doctor first? a. A 23-year-old man who states he had difficulty maintaining an erection last night b. A 44-year-old man who has perineal pain and a temperature of 100.4° F c. A 62-year-old man who has light pink urine after having a TURP 3 days ago d. A 66-year-old man who has a painful erection that has lasted over 9 hours

The nurse, caring for a Jewish client with respiratory alkalosis, tells another nurse that "Jewish families are so hard to deal with; all they do is complain." What behavior is the nurse demonstrating? A) Culture shock B) Discrimination C) Prejudice D) Stereotyping

The results of a client's arterial blood gas sample reveal an oxygen level of 72 mmHg. For which associated health problem should the nurse assess this client? A) Communication B) Perfusion C) Fluid and electrolyte imbalance D) Cognition

Upon entering a room, the nurse quickly scans the environment and then immediately assesses the client for manifestations of metabolic acidosis. What observation did the nurse make that precipitated this assessment of the client? A) Client sleeping with the head of the bed flat B) Half of the client's lunch tray uneaten C) One formed stool in the bedside commode D) 1000 mL of intravenous 0.9% normal saline infused in 2 hours

When obtaining the health history from a client, which factor would lead the nurse to suspect that the client has an increased risk for sexually transmitted infections (STIs)? a) Hive-like rash for the past 2 days b) Clear vaginal discharge c) Weight gain of 5 lbs in one year d) Five different sexual partners

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.

Which intervention has the highest priority when caring for a client diagnosed with RA? a. Encourage the client to ventilate feelings about the disease process b. Discuss the effects of disease on the client's career and other life roles c. Instruct the client to perform most important activities in the morning d. Teach the client the proper use of hot and cold therapy to provide pain relief

Which of the following anti-hypertensive medications is contraindicated for clients with renal insufficiency? a) beta-adrenergic blockers b) calcium-channel blockers c) direct-acting vasodilators d) angiotensin-converting enzyme inhibitors

Which of the following may be included in the diet of the client with chronic renal failure? a) orange slices b) watermelon slices c) cantaloupe slices d) apple slices

Which psychological manifestation is not associated with pre-menopause? a Mood swings b Forgetfulness c Loss of libido d Anxiety

Which psychosocial problem would be priority for a client diagnosed with RA? a. Alteration in comfort b. Ineffective coping c. Anxiety d. Altered body image

The nurse has identified that a client who sustained an open femoral fracture is at risk for infection. Which intervention should be implemented to prevent infection? (Select all that apply.) A. Using sterile technique with dressing changes B. Assessing temperature during every shift C. Providing pain medications as indicated D. Assessing the wound for size, color, or presence of drainage E. Administering prophylactic antibiotics per order

N151 Final Exam NCLEX Questions (No Rationale)

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