NCLEX Practice Questions

The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit?

1. Autocratic

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction?

2. "I need to breast-feed, especially for the first 6 weeks postpartum."

The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform?

1.Assessing how often the client swallows Rationale:Assessing how often the client swallows after nasal surgery is a priority action because this is a sign of bleeding. Checking vital signs and looking at the external packing for bleeding are important but not a priority for nasal surgery clients. Determining if the client can breathe through the unaffected nostril is an essential reasonable postoperative assessment.

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?

1.Elevate the shoulders.

A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching?

2."It is a fast-growing infectious disease."

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

2."Your type of pelvis is the most favorable for labor and birth."

A client is having a diagnostic workup for colorectal cancer. Which factors in the client's history place the client at increased risk for this type of cancer? Select all that apply.

2.A diet high in fats 4.A diet high in carbohydrates 5.A history of inflammatory bowel disease

A client is scheduled for an oral cholecystogram. The nurse should plan to prescribe which type of diet for the evening meal before the test?

2.Low-fat

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply.

2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate?

2.Notify the health care provider (HCP)

The home health nurse visits a client with suspected scabies. Which precaution should the nurse institute during the assessment of the client?

3.Wear a gown and gloves.

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action?

4.Aspirate the fluid, advance the catheter farther, and reinflate the balloon. Rationale:If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid should be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter should not be withdrawn slightly because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon should not continue to be inflated because the pain is not normal and will not go away

An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information?

4."My contact lenses can be worn if they are cleaned properly."

A just delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism?

4.Evaporation

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse implement?

3.Instruct the client that these are common and may occur throughout the pregnancy.

The nurse is assisting a female client to collect a midstream urine specimen. How should the nurse implement aseptic technique?

3.Making sure that the fingers avoid touching the inside of the collection container

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?

3.Palpating over the breast tissue to assess and compare vibrations from 1 side to the other

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

4.A sedentary 65-year-old woman who smokes cigarettes

The nurse is caring for a client with newly diagnosed human immunodeficiency virus (HIV). Besides preventing the transmission of the disease, what are the goals of medication therapy? Select all that apply.

1.Decreasing the viral load 2.Delaying disease progression 5.Maintaining or increasing CD4+ T cell counts 6.Preventing HIV-related symptoms and opportunistic diseases

A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort?

1.Directly observed therapy

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client?

3."The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated."

A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be?

3."The child should be kept home until the antibiotic eye drops have been administered for 24 hours." 4.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

3.Ask the client to shrug the shoulders against the nurse's resistance.

The school nurse is providing a nutritional counseling session to a group of adolescents. The school nurse should instruct the adolescents that which item is a good source of vitamin C?

3.Sweet potatoes

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first?

4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

4.Over the fifth intercostal space in the left midclavicular line

The clinic nurse is teaching a pregnant woman about the warning signs in pregnancy. Which, if identified as a warning sign by the woman, should indicate a need for further education?

4.Presence of irregular, painless contractions

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level?

4.Punishment and reward

The nurse consults with a nutritionist regarding the dietary preferences of an Asian American client. Which food should be included in the dietary plan?

1.Rice Rationale:Asian Americans' food preferences may include raw fish, rice, and soy sauce. Hispanic Americans may prefer beans, fried foods, spicy foods, chili, and carbonated beverages. European Americans may prefer carbohydrates and red meat. African Americans' food preferences may include pork, greens, rice, and fried foods.

The health care provider's prescription reads levothyroxine, 100 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

1 tablet

Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?

2. "The UV light treatments are given on consecutive days."

The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply.

2.Early menarche 4.Family history of breast cancer 5.High-dose radiation exposure to chest 6.Previous cancer of the breast, uterus, or ovaries 2,4,5,6

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)?

2.Tripod position

The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk?

3. Review hand washing techniques and pericare procedures with the client.

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client?

4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply.

1. "I am going to need to bottle-feed my baby." 2. "I need to wash my hands before and after bathroom use." 3. "I can transmit the infection to my baby when I breast-feed." 5. "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

A client with status epilepticus has been prescribed phenytoin to be given by the intravenous (IV) route. The nurse administering the medication is careful not to exceed which recommended infusion rate?

1. 50 mg/min Rationale: IV administration of phenytoin is performed slowly (no faster than 50 mg/min) because rapid administration can cause cardiovascular collapse. It should not be added to any existing IV infusion because this is likely to produce a precipitate in the solution. Solutions are highly alkaline and can cause local venous irritation

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child?

1. Assess the child's physical status.

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.

1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

1. Notify the health care provider (HCP). Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period?

1. Vital signs

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

1. Vital signs

A mother of a 4-year-old expresses concern because her hospitalized child has begun thumb sucking. The mother states that this behavior began 2 days after hospital admission. Which response by the nurse is appropriate?

1."It is best to ignore the behavior."

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

1."The enema will be given while I am sitting on the toilet." Rationale:The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying (Sims') position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible since this will promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping

Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? Select all that apply.

1.10 to 20 mL is the stomach capacity of a 1-day-old newborn 4.90 to 150 mL is the stomach capacity of a 1-month-old infant

The nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What should the nurse do next?

1.Discard the IV tubing and use a new set for the infusion.

The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client?

1.Drawing

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions?

1.Droplet precautions

The nurse is providing dietary instructions to help with diabetes control for a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse should provide the client with which best instruction?

1.Eat meals at approximately the same time each day

A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic?

1.Is painless and indurated

The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are some of the initial assessment techniques or interventions the nurse should employ? Select all that apply.

1.Palpation 2.Inspection 3.Percussion 5.Bladder scanner Rationale:Control of urination may return immediately after surgery or may not return for hours after general or regional anesthesia. The effects of preoperative medications (especially atropine), anesthetic agents, or manipulation during surgery can cause urine retention. Assessment may be difficult to perform after lower abdominal surgery. Assess for urinary retention by inspection, palpation, and percussion of the lower abdomen for bladder distention or by the use of a bladder scanner. Auscultation and inserting a Foley catheter are not interventions for initial postoperative urinary problems

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client?

1.Private room or cohort client

The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?

1.The client begins to wash the newborn by starting with the eyes and face.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission?

1.The disease is transmitted by droplet nuclei.

A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction?

2."I should use a hot mist vaporizer to liquefy secretions."

The community nurse is conducting a health promotion program, and the topic of the discussion relates to the risk factors for gastric cancer. Which item, if identified as a risk factor by a client, indicates a need for further discussion?

2.A low-fat diet

A client has been given lansoprazole for the chronic management of Zollinger-Ellison syndrome. The nurse instructs the client to take which product for pain while taking this medication?

2.Acetaminophen

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse determines that this finding occurs in which condition?

2.Iron deficiency Rationale:Decreased RBC counts occur in clients with vitamin B6 and B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, and pernicious anemia. A decrease in the RBC count also may be noted in the older client. Increased RBC counts are noted in clients with the disorders in the remaining options.

The nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should tell the mother that care of the infant should include which appropriate measure?

2.Pad crib rails and table corners.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

2.Particulate respirator, gown, and gloves

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

2.Potassium Rationale:The serum potassium level tends to rise with metabolic acidosis. This is because potassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte should be monitored closely while the client is treated.

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection?

2.Removing the gown without rolling it from inside out

The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason?

2.Results in detection of a more accurate number of cases

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

2.Vitamin B12

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

2.Wearing a gown and gloves

The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding the cause of this syndrome?

3."Do you use tampons during your menstrual period?"

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?

3.Encourage the client to discuss the use of an herbal substance with the health care provider (HCP).

A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse providing care for the client administers an opioid analgesic to relieve the pain, as prescribed. What is the next nursing action for this client?

3.Ensure the call bell is within the client's reach Rationale:The nurse should ensure that the call bell is within reach for the client who receives an opioid analgesic. The nurse also instructs the client to call for assistance if it is necessary to get out of bed to prevent injury once the medication has taken effect. Dimming the light in the room is the next most helpful action. The name bracelet should have been checked before administering the medication. It is unnecessary to do range of motion at the site of injection

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement should the nurse make to the client?

3.Hands should be washed thoroughly before holding the infant.

The nurse is preparing to insert an intravenous (IV) angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site?

3.Using a circular motion from the center outward

The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?

3.Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

4. A client with asthma who requested a breathing treatment during the previous shift

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client?

4."An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instruction?

4."I should wear knee-high hose, but I should not leave them on longer than 8 hours."

The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why he is receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication?

4."Medications given this way are absorbed more quickly than by other routes." Rationale:Medications given parenterally are absorbed more quickly than by other routes. The intramuscular route provides faster medication absorption than the subcutaneous route because of the greater vascularity of the muscle. The remaining options do not answer the client's question and may be belittling or incorrect.

The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client?

4.A complete health database

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others?

4.Blood and body fluid precautions

A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action?

4.Contact the health care provider (HCP).

The nurse has made an error in documenting an assessment finding in the client's record. What action should the nurse take to correct the error?

4.Draw a line through the error, initial and date the line, and then provide the correct information.

The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate?

4.Encourage the client to recognize that the body changes need to be dealt with.

The nurse prepares the client for irrigation of an abdominal wound. After preparation, the nurse would appropriately don which item to perform the procedure? Click on the Question Video button to view a video showing preparation procedures.

4.Gloves, gown, and goggles

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

4.Gloves, gown, goggles, and a mask or face shield

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the hematocrit value is 30% (0.30). The nurse determines that this hematocrit value is most likely to be associated with which condition?

4.Iron deficiency anemia ationale:A hematocrit of 30% (0.30) or less indicates iron deficiency anemia. Decreased values occur in leukemia, acute hemorrhage, iron deficiency anemia, and hemolytic anemia. The conditions in the remaining options represent conditions in which an elevated hematocrit would be noted.

The parents of a child with a cleft palate are concerned and ask the nurse when the palate will be repaired. The nurse should plan to base the response on which information about cleft palate repair?

4.Repair usually is performed between 6 months and 2 years

A client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What should the nurse tell the UAP?

4.Standard precautions are sufficient because the disease is transmitted sexually.

A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed?

4.Supine in semi Fowler's Placing the client in semi-Fowler's position allows gravity to aid in drainage of the abdominal cavity. This helps prevent the formation of abscesses high in the abdomen. Abscesses in this location could rupture, potentially causing peritonitis. The color, odor, and amount of vaginal secretions also are noted and recorded. Options 1, 2, and 3 will not aid in gravity drainage.

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control?

4.The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing.

The nurse at a well-baby clinic is assessing the motor development of a 24-month-old child. On the basis of the age of the child, the nurse expects to note what as the highest-level developmental milestone?

4.The child opens a door by turning the doorknob.

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance?

4.The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

4.The functional status of the vestibular apparatus in the inner ear

The school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list?

4.Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits.

The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observation made by the instructor indicates the need for further teaching?

2.The student dons the sterile gloves without washing the hands.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

2.Three sputum cultures are negative.

The community health nurse is preparing an educational session for a group of women and will be discussing the primary prevention strategies and treatment measures for breast cancer. What information should the nurse include in the educational session?

2.Treatment decisions are based on a woman's overall health.

A health care provider prescribes 3000 mL of 5% dextrose in water (D5W) to infuse over a 24-hour period. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

21 gtt/min Total volume × Drop factor-------------------------- = gtt/minTime in minutes3000 mL × 10 gtt 30,000---------------- = ------ = 20.83 gtt/min1440 minutes 1440= 21 gtt/min (rounded)

A health care provider's prescription reads phenytoin 0.3 g orally daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

3

The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother?

3."One week after the onset of jaundice."

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?

3.0.9% sodium chloride Rationale:Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation?

3.Ask the nurse to refrain from eating and drinking in that area.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction?

3.Hold the gum between the cheek and teeth periodically

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation?

3.Pregnancy for 2 to 3 months after the vaccination

The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy?

3.Pregnancy greatly increases the risk of malnourishment for the mother.

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?"

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?

1. Reflecting a cultural value

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?

"I should not use insect repellents because it will attract the ticks."

The nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease?

"My wife should get the vaccine."

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

1.The nail beds

The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply.

1. Hold the finger in a dependent position during the test. 2. Use gentle pressure to obtain an adequate amount of blood. 4. Obtain the blood specimen by puncturing the lateral side of the finger.

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?

1. Information regarding shelters

Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.

1. Latino American man 2. Native American man 4. Hispanic American man 5. African American woman

The student nurse is caring for an infant with a tracheostomy and is preparing to suction the infant. The nursing instructor should intervene if the nursing student stated she would take which action to perform this procedure?

1. Limit insertion and suctioning time to 15 seconds to prevent hypoxia.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?

1. Monitor closely for harm to self or others.

The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement?

1."I should use disposable plates, forks, and knives."

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

1.Hypotension Rationale:Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action?

1.Irrigate the eyes with water.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

1.Prolonged bed rest Rationale:The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?

2. "I should use polyunsaturated oils in my diet." Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian

A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment should include which parameters? Select all that apply.

2. The client's vital signs 4. The client's level of consciousness 5. The patency of intravenous lines

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs?

2. Three sputum cultures are negative.

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention?

2. To have a window cut in the cast

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

2.Apply a warm compress. Rationale:The application of a warm compress enhances the absorption of blood in the hematoma. Allen's test is performed before the collection of the specimen to assess collateral blood flow. Heparinized syringes are used for the collection of an arterial blood gas, but no heparin is administered to a client. The antidote for heparin is not administered at this time unless prescribed. The laboratory department is not responsible for collecting the arterial blood gas specimen. Additionally, there is no useful reason to notify the hospital laboratory supervisor.

The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation?

2.Speak and move slowly toward the client while assessing the client's needs. Rationale:Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to become agitated and could trigger a violent episode. Remaining at the entrance of the room may make the client feel alienated. If the client's agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option. Walking up behind the client may cause the client to become startled and react violently

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?

3. Hypervolemia Rationale: Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client's signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia.

The nurse is teaching a client about what to expect during a gallium scan. The nurse should include which item as part of the instructions?

3. The procedure takes about 30 to 60 minutes to perform. Rationale: A gallium scan requires the injection of gallium isotope 2 to 3 hours before the procedure; therefore, the procedure is invasive. The procedure takes 30 to 60 minutes to perform. The client will lie down during the procedure and must lie still. There is no special aftercare.

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding?

3.Finding 2 vessels may indicate an increased risk for other congenital anomalies.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

4. "We need to remind him to turn his head to scan the lost visual field." Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation?

4. Is likely to have perceptual and spatial disabilities Rationale: The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities

The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse should plan to admit the client to a room that has which properties?

4.Venting to the outside, 6 air exchanges per hour, and ultraviolet light

The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan?

Always apply the condom before inserting the penis into the vagina.

A man has been admitted to the surgical unit after hernia repair surgery. The medical record reports that the client is human immunodeficiency virus (HIV) positive. The nurse should implement which precautions for this client?

Standard precautions

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? Click on the image to indicate your answer.

sims Rationale:To administer an enema, the nurse assists the client into the left side-lying (Sims') position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thereby improving the retention of solution. Option 1 is a prone position. Option 3 is a lithotomy position. Option 4 is a dorsal recumbent position.

The nurse at a well-baby clinic is providing nutrition instructions to the mother of a 1-month-old infant. What instruction should the nurse give to the mother?

2.Breast milk or formula is the main food

A client who visits the health care provider's office for a routine physical examination reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse should check for which manifestations?

2.Complaints of weakness and lethargy

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action?

2.Determine if there are any disconnections in the ventilator tubing.

The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action should be implemented?

2.Document the finding in the electronic health record

The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poster is planned that will list sexual behaviors in 1 of 2 columns, "safe" and "not safe." Which behavior should the nurse place in the "not safe" column?

.Use of natural skin condoms

A health care provider prescribes ketorolac 15 mg intramuscularly stat for a postoperative client in pain. The medication label states ketorolac 30 mg per mL. How many milliliters should the nurse prepare to administer to the client? Fill in the blank.

0.5 mL

TThe school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list?

4.Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits. Rationale:Pediculosis capitis is an infestation of the hair and scalp with lice. Thorough home cleaning is necessary to remove any lice or nits that may fall from the host. Combs and brushes should be soaked in hot water for 10 minutes or a pediculicide for 1 hour. Anti-lice sprays are unnecessary and may be harmful. In addition, they should never be used on a child or on bedding or linens. Bedding and linens should be washed with hot water and dried on a hot setting. Items that cannot be washed should be dry cleaned or sealed in plastic bags in a warm place for 2 weeks

A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period?

4.Within 20 to 30 minutes of application Rationale:A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. Therefore, the remaining options are incorrect

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction?

1. "I will clean up any spills from the diaper with diluted alcohol."

A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath?

1.A gown and gloves

A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time?

1.High-fiber diet Rationale:Constipation is the probable cause of the client's lack of bowel movements. Constipation is the difficult or infrequent passage of stools, which are hard and dry. Constipation has numerous causative factors, including psychogenic, lack of physical activity, inadequate intake of food and fiber, and medication influences. A high-fiber diet often is indicated for constipation because it will promote bulk and encourage intestinal peristalsis. A full liquid diet will add fluids but no bulk to help relieve the constipation. A low-fiber diet has little bulk to assist with the needed peristalsis. Decreasing the amount of sodium in the diet has little, if any, effect on constipation

The nurse is assisting the health care provider during a colonoscopy procedure. The nurse helps the client to assume which position for the procedure?

1.Left Sims' Rationale:The client is placed in the left Sims' position for the procedure. This position uses the client's anatomy to the best advantage for introducing the colonoscope. The left Sims' position would also be used for giving the client an enema while lying down. Therefore, options 2, 3, and 4 are incorrect

The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position?

1.Left-sided lateral Sims' position Rationale:When administering an enema, the client is placed in a left-sided Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The client is lying on his or her side, with the body turned approximately 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45- to 90-degree angle. Options 2, 3, and 4 are incorrect positions.

The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure?

1.Limit caffeine intake.

A nurse is caring for an infant with a respiratory infection and is monitoring the infant for signs of dehydration. What is the nurse's best action to determine fluid loss in the infant?

1.Monitor body weight.

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most importantelement of the nurse's focused assessment of the client's smoking history?

1.Number of pack-years

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.

2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?

2. Place the client in high Fowler's position.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?

4.Keep the client on NPO (nothing by mouth) status.

An unlicensed assistive personnel (UAP) is caring for a client who has an indwelling urinary catheter. Which action by the UAP would indicate the need for further instruction in the care of the client?

2.Allowed the drainage tubing to rest under the leg

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?

2.Assess the vagina and cervix with a gloved hand.

The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved?

2.Avoids transmitting the virus to others in the group home

The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse should ask whether which signs and symptoms have resolved?

2.High fever, abdominal pain, vomiting, and diarrhea

The nurse is providing instructions to the mother of a child with human immunodeficiency virus infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule?

3."Family members in the household need to receive the influenza vaccine."

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?

3."I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."

The nurse teaches the mother of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the mother indicates a need for further teaching?

3."It is all right to share towels and washcloths as long as they are bleached after use."

The nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse instructs the parents that if the child comes into contact with poison ivy to take which action?

4. Shower the child immediately, lathering and rinsing the exposed skin several times.

The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?

4."This is necessary to assist in identifying potential infections that may need to be treated."

The nurse is evaluating the laboratory test results for a client with diabetes mellitus seen in the health care clinic. The nurse determines that which glycosylated hemoglobin level value shows poor adherence to therapy?

4.10% Rationale:The normal glycosylated hemoglobin in an adult without diabetes is <6%. Levels >8% indicate poor diabetic control and need for adherence to regimen or changes in therapy. The results in the remaining options indicate adequate control.

The nurse has a prescription to infuse 1000 mL of 5% dextrose in lactated Ringer's solution at 80 mL per hour. The nurse time-tapes the intravenous (IV) bag with a start time of 0900. After making hourly marks on the time-tape, the nurse should note which completion time for the bag?

4.2130 At a rate of 80 mL/hour, the 1000-mL bag will be finished infusing in 12.5 hours. This brings the end time to 2130 using military time.

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?

4.Allow the client to interact with others in his or her (adolescent) same age group.

Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position?

4.It facilitates instillation of the enema solution into the colon. Rationale:The sigmoid and descending colons are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus. The other options are incorrect.

A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse should try to limit which food that is most likely to cause this taste for the client?

1.Beef

A client is scheduled to begin medication therapy with valproic acid. The nurse looks for the results of which laboratory test(s) before administering the first dose?

1. Liver function tests Rationale: Gastrointestinal effects from valproic acid are common and typically mild, but hepatotoxicity, although rare, is serious. To minimize the risk of fatal liver injury, liver function is evaluated before initiation of treatment and periodically thereafter. The other options are unrelated to the use of this medication

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?

1.Stroking the foot from the heel to the toe

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply.

1. Yawning 3. Swallowing 4. Chewing gum 5. Sucking on hard candy Rationale: Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane. Humming does not affect pressure

The nurse is collecting data from an African American client scheduled for surgery. Which questions would be most appropriate for the nurse to ask on initial assessment? Select all that apply.

1."Do you ever experience chest pain?" 2."Do you have any difficulty breathing?" 5."Do you frequently have episodes of headache?" Rationale:In the African American culture, it is considered to be intrusive to ask personal questions on the initial contact or meeting. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. Psychosocial data are the least priority during the initial data collection. Additionally, cardiovascular, neurological, and respiratory data include physiological assessments that would be the priority

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to this stage of development?

1.This stage is associated with toilet training

The nursing instructor determines that the nursing student understands the purposes of standard and transmission-based precautions if which statements are made? Select all that apply.

1."They prevent transmission of organisms from client to client." 2."They prevent transmission of organisms from health care providers to clients." 3."They prevent transmission of organisms from clients to health care providers." 6."They prevent transmission of organisms from health care providers and clients to people outside of the hospital."

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply.

1.A 47-year-old mother of a child with cystic fibrosis 2.A 54-year-old man scheduled for a routine diabetes check 4.A 35-year-old registered nurse scheduled for an annual pelvic exam 5.An 87-year-old woman from a nursing home scheduled for a surgical follow-up

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Based on her last normal menstrual period, she is 8 weeks' gestation. Appropriate physical assessments are completed. Which findings are anticipated to be present at this time? Select all that apply.

1.A softening of the cervix 3.Bluish discoloration of the vaginal tissue 4.The presence of human chorionic gonadotropin in the urine

The nurse is providing dietary teaching to a client who is receiving a potassium-retaining diuretic about foods that are low in potassium. Which foods should the nurse include on a list of foods with low potassium content?

1.Apple Rationale:One medium apple with skin provides approximately 159 mg of potassium per serving, so it has the lowest potassium content of these choices. One large carrot has 341 mg of potassium. Raw spinach (oz) provides 470 mg of potassium. One medium avocado provides the highest potassium content, 700 mg.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?

1.At 1 minute after birth and 5 minutes after birth

The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client?

1.Avoid frequent douching.

The nurse is caring for a client with chronic kidney disease. The nurse knows that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply.

1.Help regulate blood pressure. 4.Assist to regulate acid-base balance. 5.Convert vitamin D to an active form. 6.Produce erythropoietin for red blood cell synthesis. Rationale:Besides maintaining urinary elimination, the kidneys are also involved with helping to regulate blood pressure, assisting in regulating acid-base balance, converting vitamin D to an active form, and producing erythropoietin for red blood cell synthesis. The kidneys do not encourage immunosuppression and do not stimulate the liver to secrete enzymes.

The nurse is caring for a client on the oncology unit who has developed stomatitis during chemotherapy. The nurse should plan which measure to treat this complication?

1.Rinse the mouth with diluted baking soda or saline.

The nurse is providing instructions for a client who will collect a stool specimen for an occult blood test. The nurse instructs the client that it is best to avoid which food for 3 days before collection of the stool specimen?

1.Turnips Rationale:The nurse would instruct the client to avoid red meat, poultry, fish, turnips, horseradish, and foods such as fruits and vegetables for 3 days before and during testing. These foods may alter test results. It is not necessary to avoid the items in the remaining options.

The health care provider prescribes heparin sodium 800 units per hour, to be given by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled heparin 25,000 units in 500 mL of normal saline. An infusion pump must be used to administer the medication. The nurse should set the infusion pump at how many milliliters per hour to deliver the correct dose? Fill in the blank.

16 mL/hr Rationale:Calculation of this problem can be done using a 2-step process. First, you need to determine the concentration of the solution; that is, the amount of heparin in 1 mL. The next step is to determine the infusion rate, or milliliters per hour.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

2. "Do you plan to have any other children?" Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure

Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)?

2. A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4°F (38.6°C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg Rationale: The role of an RRT is to provide internal consultative services to staff nurses to detect client problems early. Absence of urine output and temperature and blood pressure elevation describe a client who may be rejecting a transplanted kidney. The constellation of symptoms described indicates possible rejection. Internal consultation could validate that assessment. The remaining options indicate expected characteristics of the clients described and provide no indication of need for RRT consultation

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first?

2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued?

2. A fetal heart rate of 90 beats/minute Rationale: A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

2. Activate the emergency response plan. Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur

A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priority action in the care of this client?

2. Assign the client to a private room.

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit?

2. Assigning the client to a room at the end of the hall

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.

2. Battery 3. Assault 5. False imprisonment

A child must wear a brace for correction of scoliosis. The nurse creates a plan of care knowing the child is at risk for which problem?

2. Breaks in skin integrity Rationale: Braces for treatment of scoliosis usually are worn 16 to 23 hours a day. The skin should be kept clean and dry and inspected for signs of redness or breakdown. Therefore, breaks in skin integrity are the client problem that should be included in this child's plan of care. The brace assists with posture, so mobility is not an issue. The brace does not compromise the respiratory status, so oxygenation is not decreased. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace

The home care nurse is assigned to visit a Mexican-American client to perform an admission assessment. On initially meeting the client, what should the nurse do?

2. Greet the client with a handshake.

The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which solution to clean the site?

2.Sterile water

The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply.

2. Notify the health care provider (HCP). 5. Prepare for endotracheal tube (ET) placement. 6. Insert an orogastric tube and connect it to low suction. Rationale: Worsening respiratory distress, audible bowel sounds in the chest, and a flat or scaphoid abdomen are all signs and symptoms of a congenital diaphragmatic hernia. For this condition to be verified, appropriate x-rays must be prescribed by the HCP. If verified, operative intervention is necessary. As mechanical ventilation is administered, the bowel fills with air, thus worsening the respiratory status of the infant; therefore, gastrointestinal decompression is necessary as well as ventilation via an ET tube rather than a bag and mask. There is no evidence in the question that the infant requires chest compressions. The infant must be kept NPO (nothing by mouth) for operative intervention and to decrease gastric distention. Proper positioning for this condition is supine with the head elevated

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem?

2. Place all objects within the left visual field. Rationale: Hemianopsia is blindness in half of the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual field deficit

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply.

2. Provide crisis counseling. 3. Identify and train personnel. 6. Handle inquiries from families.

The nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low and places the client on neutropenic precautions. Which interventions are components of these types of precautions? Select all that apply.

2. Removing fresh-cut flowers from the client's room 4. Instructing family members on the proper technique for hand washing 5. Instructing family members to wear a mask when entering the client's room

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

2. Support the mother in her reaction to the newborn infant. Rationale: Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action?

2.Identify 3 numbers or letters traced in the client's palm

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

2.Inhalation of bacterial spores 3.Through a cut or abrasion in the skin 6.Ingestion of contaminated undercooked meat

The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next?

2.Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. Rationale:The balloon is behind the opening at the catheter tip. The catheter is inserted 7 to 9 inches (18 to 23 cm) after urine begins to flow, providing sufficient space to inflate the balloon and ensuring that the balloon has passed through the entire urethra and into the bladder. Inflating the balloon in the urethra could produce trauma. The catheter should be neither withdrawn nor advanced until resistance is met.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

3. "I drink hot chocolate before bedtime." Rationale: Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest

he nurse is caring for a slightly intoxicated newly admitted Native American client with gallbladder disease. Based on the client's diagnosis, what dietary issue could be causing this client's problem?

3. Fried bread and mutton prepared in lard Rationale: Native American diets include fried bread and mutton prepared in lard, and these dietary issues have contributed to the increased risk of gallbladder disease in this population. Alcohol abuse, vitamin D deficiency, and corn in one's diet do not cause gallbladder disease

A client with psoriasis is being treated with calcipotriene cream. Administration of high doses of this medication can cause which side or adverse effect?

3. Hypercalcemia Rationale: Calcipotriene, an analogue of vitamin D3, is indicated for mild to moderate psoriasis. Responses are equal to those achieved with medium-potency topical glucocorticoids. The most common adverse effect is local irritation. Unlike glucocorticoids, calcipotriene does not cause thinning of the skin. At high doses, calcipotriene has caused hypercalcemia. Alopecia and hyperkalemia are not associated with this medication

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care?

3. Interruption in physical mobility Rationale: Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by demyelination of the neurons. Interruption in physical mobility is most appropriate for the client with multiple sclerosis experiencing muscle weakness, spasticity, and ataxic gait. The remaining options are not related to the data in the question

Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?

3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice Rationale: Members of Orthodox Judaism adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered

A client taking carbamazepine asks the nurse what to do if a dose is inadvertently missed. The nurse responds that which action should be taken?

3. Take the dose as long as it is not close to the time for the next dose. Rationale: Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, as long as it is not close to the time that the next dose is due. The medication should not be double-dosed. If more than 1 dose is omitted, the client should call the HCP.

A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the HCP if the client is also taking which medication?

3. Vitamin A

The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?

3.Properly glazed pottery Rationale:Paint chips, soil contaminated with lead, lead solder used in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

3.Removing the client from any immediate danger

An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the mother to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the mother that the child is at which stage of Piaget's cognitive development?

3.Sensorimotor development

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

3.Smoked sausage Rationale:Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables, which are low in sodium.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

3.The client was found lying on the floor.

A health care provider's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL." The nurse prepares to draw up how many milliliters to administer 1 dose?

4. 0.925 mL Rationale: Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point 3 places to the right: 1 g =1000 mg

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance?

4. A previous dose of hepatitis B vaccine or component Rationale: A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider (HCP) suspects appendicitis. Which assessment finding should the nurse immediately report to the HCP?

4. Sudden relief of abdominal pain Rationale: A sudden relief of pain from a suspected appendicitis is commonly indicative of a ruptured appendix. This places the individual at risk for peritonitis and shock. The HCP should be notified immediately because of the need to begin intravenous antibiotics to prevent further complications. Although increasing complaints of pain is a concern, the higher priority is sudden relief of pain because of the risk of peritonitis and shock. Temperature should be monitored but is not of highest priority. The child will be placed on NPO (nothing by mouth) status in anticipation of surgery; therefore, option 4 is incorrect

The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents?

4.Monitor for appropriate weight gain patterns.