NCLEX Practice Questions HURST REVIEW (Adult Health)

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

4. Fever

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

3. Tracheal deviation and dyspnea

Which food selections would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream

1. Roasted almonds

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

2. Grilled pork chops in peach sauce, baked sweet potato, sherbet

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

3. Check home environment for potential hazards.

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

3. Hypokalemia

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Select all that apply 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per nonrebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab S

3. Obtain client's blood pressure. 5. Auscultate lung sounds.

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

4. "I should avoid fresh apples and strawberries."

The edrophonium (Tensilon) test has been prescribed for a client. Which statement by the client would indicate to the nurse that the client understands this test? 1. "This medication will be given to me as an IM injection immediately after my muscles are tired." 2. "This test will determine if I have multiple sclerosis." 3. "The test is positive if my muscles do not get stronger after injection with this medication." 4. "I will be asked to perform a repetitive movement to test my muscles."

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

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

1. Administer pain medicine

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

2. Prompt capillary refill < 2 seconds after blanching

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? Select all that apply 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level altitude

1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion

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

1. Administer 100% oxygen per mask.

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

1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 mL/hr

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

1. Client reports chest discomfort. 2. Legs elevated 15 degrees. 4. Client reports slight tingling to right foot. 5. Left pedal pulse 2+/4+, Right pedal pulse 1+/4+.

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

1. Calf liver 2. Feta cheese 4. Shrimp 5. Tuna

A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.

2. Wrap each digit individually to prevent webbing.

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

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

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

1. Parenting classes for first time parents 2. Healthy diet classes for school-age children 5. Community exercise classes to promote weight loss

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

1. Private room

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

1. Renal

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

1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor

The nurse is preparing discharge teaching for a client diagnosed with peripheral vascular disease (PVD). Which teaching points should the nurse include about foot and leg care? Select all that apply 1. Wear soft cotton socks 2. Avoid hot whirlpools 3. Rub feet dry 4. Wash feet every other day 5. Clear pathways in house

1. Wear soft cotton socks 2. Avoid hot whirlpools 5. Clear pathways in house

When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? Select all that apply 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet.

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

1. Warm the room.

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

3. Aspiration pneumonia

The nurse is providing care to a client who had an endoscopic retrograde cholangiopancreatogram (ERCP) two hours ago. Which finding would indicate a possible complication? 1. Occasional cough 2. Sore throat reported 3. Abdominal pain rated 8/10 4. Drowsy

3. Abdominal pain rated 8/10

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

3. Check that identification band is in place.

Which statement by the nurse would be the correct response to a client who is postmenopausal with a uterus when the client asks about temporary hormonal therapy for hot flashes? 1. "Hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed." 2. "Unopposed estrogen hormonal therapy would be most appropriate." 3. "Hormonal therapy is an outdated treatment and can no longer be prescribed so you should try an alternative such as ginseng." 4. "Hormonal therapy is not an option for women with a uterus so you may need to consider a hysterectomy."

1. "Hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed."

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? Select all that apply 1. "The best way to prevent HIV is to abstain from sex." 2. "Contraceptives should contain spermicide N-9." 3. "Douching is recommended after intercourse." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

1. "The best way to prevent HIV is to abstain from sex." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? Select all that apply 1. Abdominal discomfort 2. Alopecia 3. Butterfly rash on face 4. Fever 5. Weight gain

1. Abdominal discomfort 3. Butterfly rash on face 4. Fever

The nurse is examining a client in the emergency department who is suspected of having acute cholecystitis? What data obtained by the nurse would help to validate this problem? Select all that apply 1. Abdominal guarding 2. Anorexia 3. Positive murphy's sign 4. Reports left shoulder discomfort 5. Steady epigastric pain

1. Abdominal guarding 2. Anorexia 3. Positive murphy's sign discomfort 5. Steady epigastric pain

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

1. Assisting with turn, cough, and deep breathing (TCDB)

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

1. Bruising at the umbilicus. 2. Fever with tachycardia. 4. Pain radiating to back.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? Select all that apply 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1. Diabetes mellitus. 2. Cigarette smoking. 4. Long-term use of corticosteroids.

A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? Select all that apply 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Increase protein rich foods in the diet. 4. Cut fingernails short 5. Provide mouth care prior to meals

1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 4. Cut fingernails short 5. Provide mouth care prior to meals

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Identify the client's symptoms promptly.

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

1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbant position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

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

1. Mild disorientation 2. Difficulty with words and numbers

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

1. Urine output of 860 mL / 24 hours.

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? Select all that apply 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

2. Weight gain of 4 pounds in one week 5. Serum potassium of 3.2 mEq

A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological

3. Airway

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

3. Assist the client into a supine position in bed.

A client has been admitted with a diagnosis of portosystemic encephalopathy (PSE) secondary to Laennec's cirrhosis. The client is lethargic with slurred speech and is oriented only to self. Assessment findings include grossly distended abdomen, bruised and jaundiced skin, fine bibasilar crackles and +4 pitting edema to lower extremities. The nurse is aware that what lab result is most likely responsible for the client's neurological deterioration? 1. Albumin 2.0 gm/dl 2. Sodium 129 meq/L 3. Bilirubin 2.0 gm/dl 4. Ammonia 80 mcg/dl

4. Ammonia 80 mcg/dl

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? Select all that apply 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1. Age over 65 years. 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

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

1. Areflexia 2. Dysphagia 4. Orthostatic hypotension

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

1. Assess client's ability to perform self care. 3. Separate tasks into small manageable steps. 5. Have nursing staff spend time talking and listening to client.

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

1. Attach to a cardiac monitor

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

1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%.

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

1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 4. Advise client that urine may change color with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, fever.

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

1. Ventricular fibrillation

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output

2. Increase fluid intake

Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? Select all that apply 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L)

2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L)

A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the nurse that discharge teaching has been effective? 1. I will need to eat a low fat diet since I no longer have a gallbladder. 2. I can expect drainage from the incisions for a few days. 3. I may have some mild pain from the procedure. 4. I should plan to limit my activities and not return to work for several weeks.

3. I may have some mild pain from the procedure.

A client receiving palliative care is reporting constipation. What intervention should the palliative care nurse provide first? 1. Increase foods high in fiber. 2. Administer an enema 3. Increase fluid intake 4. Administer docusate sodium

3. Increase fluid intake

A client has been admitted to the emergency department after repeated food binging and purging by vomiting and laxative abuse. The client reports leg pains and weakness. ECG reveals a depressed ST segment and flattened T wave. Based on this data, what does the nurse anticipate that this client will need to receive first? 1. Oral fluids 2. Kayexalate enemas 3. Intravenous potassium (KCL) 4. An antidiarrheal medication

3. Intravenous potassium (KCL)

An adolescent is diagnosed with a closed head injury following a motor vehicle accident. The nurse notes clear drainage from the left nostril and is aware the priority action is what? 1. Contact the healthcare provider. 2. Carefully suction both nostrils. 3. Ask client to gently blow nose. 4. Test the drainage for glucose.

4. Test the drainage for glucose.

A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? 1. Administer oxygen. 2. Obtain a blood pressure reading. 3. Connect to cardiac monitor. 4. Raise head of bed to 90 degrees.

4. Raise head of bed to 90 degrees.

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

4. Notify the primary healthcare provider.

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

4. Notify the primary healthcare provider.

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

4. Older individual with acquired immunodeficiency syndrome

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

2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 5. Left-sided cheek twitching

The nurse is evaluating a client for compliance to the prescribed diabetic program by checking recent lab results. Based on the lab data, what should the nurse conclude regarding the client? 1. At risk for developing hypoglycemia. 2. Demonstrating good control of blood glucose. 3. At risk for developing Somogyi phenomenon. 4. Demonstrating signs of insulin resistance.

2. Demonstrating good control of blood glucose.

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

2. Vegetable soup, whole wheat toast, skim milk

A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD)

3. Trigeminal neuralgia

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

4. Notify primary healthcare provider.

A client has received discharge education post extracapsular cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "A protective eye patch will be needed for 24 hours." 2. "I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal." 3. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." 4. "When sleeping, I will avoid lying on the same side of my affected eye."

"I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal."

What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion

1. Notify the primary healthcare provider

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

1. Use 2% milk instead of whole milk 2. Eat air-popped popcorn instead of potato chips 4. Incorporate plant sources of protein

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

2. Cullen's Sign 5. Tachycardia.

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

4. Reverse Trendelenburg

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? Select all that apply 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1. "I will go to the bathroom as soon as the urge to void hits me." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

A home health nurse is planning home safety education for a client and spouse. Which actions should be included to promote fire safety in the home setting? Select all that apply 1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and a place where all family members will meet.

1. A fire extinguisher should be kept on each level of the home. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms, and test them monthly. 5. Have a planned route of exit and a place where all family members will meet.

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

1. Client has pitting edema in lower extremities.

What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.

1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 4. Educate about ferrous sulfate supplement.

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? Select all that apply 1. Diarrhea 2. Increased urination 3. Dilated pupils 4. Tachycardia 5. Nausea and vomiting

1. Diarrhea 2. Increased urination 5. Nausea and vomiting

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

1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.

1. Pay attention to fullness cues during meals. 6. Use a smaller plate for meals.

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

1. Weight gain of 2 lbs (0.907 kg) in 24 hours

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? Select all that apply 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

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

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

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

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply 1. Smokeless tobacco increases risk for lung cancer. 2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 4. Risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice. 5. Report decreased saliva to primary healthcare provider. 6. Smoking cessation.

2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 6. Smoking cessation.

A lethargic client was admitted with encephalopathy secondary to cirrhosis. The client displayed a grossly distended abdomen, fine bibasilar crackles and +4 pitting edema to lower extremities. Following three days of treatment, the client is improved enough for discharge. Vital signs are now within normal limits and lungs clear. The client's elevated ammonia level has returned to normal, though PT/PTT levels are still elevated. The nurse knows discharge teaching should include what information? Select all that apply 1. How to measure and record abdominal girth daily. 2. Keep lower extremities elevated while out of bed. 3. Emphasize the need to eliminate alcohol intake. 4. Remind client to use an electric razor to shave. 5. Check weight daily and report gain over 10 lbs/4.536 kilograms. 6. Restrict protein intake to just 40 gm. daily.

2. Keep lower extremities elevated while out of bed. 3. Emphasize the need to eliminate alcohol intake. 4. Remind client to use an electric razor to shave. 6. Restrict protein intake to just 40 gm. daily.

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

2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating

Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse's priority action immediately after the intubation? 1. Suction to clear all secretions 2. Listen for bilateral breath sounds 3. Secure the endotracheal tube 4. Obtain x-ray to verify tube placement

2. Listen for bilateral breath sounds

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

2. NG tube to low suction 3. Side-lying position with head elevated 4. Hydromorphone by PCA pump

A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care? Select all that apply 1. Approach the client from his left side. 2. Place the client's meal on the right side of the over bed table. 3. Request a consult for an ophthalmologist. 4. Stand directly in front of the client when addressing. 5. Have client look at the left side of the body.

2. Place the client's meal on the right side of the over bed table. 5. Have client look at the left side of the body.

A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm.

2. Position arm to prevent pressure to the graft site.

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

2. Protein must be limited because of elevated ammonia levels.

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

2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

The nurse is caring for a client following gastric bypass surgery. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select all that apply 1. Increase liquids with food. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating.

2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals.

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

2. Right side

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor.

2. Weight gain of two pounds.

The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture? 1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22

2. pH 7.33, PaCO2 48, HCO3 25

A nurse is caring for a client who had a total hip replacement 2 days ago. What assessment finding would be a priority concern for the nurse? 1. Small amount of red drainage on the surgical dressing. 2. Continues to report pain in hip when being repositioned. 3. Temperature of 101.8°F (38.7°C). 4. Slight swelling in the leg on the affected side.

3. Temperature of 101.8°F (38.7°C).

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

4. "What worries you most about getting out of bed?"

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

"We need to let your primary health care provider know because it may indicate a problem."

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

2. Drivers who have recently acquired a driver's license.

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position 5. Place ice packs under axilla for fever greater than 101°F (38.3°C)

1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 5. Place ice packs under axilla for fever greater than 101°F (38.3°C)

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

1. "I can get a vaccine to prevent getting the Ebola virus."

A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? 1. "I feel like food gets stuck in my throat when I eat." 2. "I have a hard time brushing my teeth properly." 3. "My fingers burn when I go outside in the winter." 4. "I get short of breath whenever I exercise."

1. "I feel like food gets stuck in my throat when I eat."

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

1. Avocados 2. Acorn squash 4. Lima beans 5. Raspberries

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

1. Bladder pain 3. Urinary frequency 4. Terminal dribbling

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

1. Don appropriate personal protective equipment (PPE).

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

1. Provide tepid water sponge bath. 2. Start an IV for fluid resuscitation. 3. Insert a nasogastric tube. 4. Pad side rails. 5. Obtain blood gases.

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Hot spots

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance would be the nurse's priority concern? 1. Hypomagnesemia 2. Hyponatremia 3. Hyperkalemia 4. Hypercalcemia

1. Hypomagnesemia

A client has been admitted to the medical unit after sustaining a stroke. The admitting nurse initiates a nursing diagnosis of unilateral neglect related to a decrease in visual field and hemianopia from cerebrovascular problems as evidenced by consistent inattention to stimuli on the affected side. What nursing interventions should the nurse initiate for this client? Select all that apply 1. Instruct client to scan from left to right to visualize the entire environment. 2. Encourage client to practice exercises independently. 3. Position bed in room so that individuals approach the client on the unaffected side. 4. Apply splints to achieve stability of affected joints. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

1. Instruct client to scan from left to right to visualize the entire environment. 3. Position bed in room so that individuals approach the client on the unaffected side. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

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

1. Loss of bone density 2. Loss of muscle mass 5. Increased fat tissue

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Patency of endotracheal tube.

The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? Select all that apply 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others.

1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 5. Smallpox victims are isolated from others.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client? Select all that apply 1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils 6. Large button closures on clothes

1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels.

The nurse is caring for a client who has an active herpes simplex 1 lesion on the lip. What measures should be implemented by the nurse? Select all that apply 1. Tell the client to avoid touching the lesion. 2. Scrub the lesion gently with soap and water prior to meals. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 4. Wear sterile gloves when applying medication to lesion. 5. Ask client to discard lip balm until lesion is resolved.

1. Tell the client to avoid touching the lesion. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 5. Ask client to discard lip balm until lesion is resolved.

A nurse has taught a group of teenage girls about breast self-awareness. Which statements by the teens would indicate to the nurse that teaching was effective? Select all that apply 1. "I should have a clinical breast exam every 5 years starting at the age of 18." 2. "Doing a monthly breast self-exam will help me learn what is normal for me." 3. "It is only important to know my maternal health history." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge." 5. "Self-breast exam should be done a few days before my menstrual cycle begins."

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

A client with tuberculosis (TB) has been coming to the health department for directly observed therapy (DOT) for the past month. Today, the client states, "I don't think I need to come back anymore. I am feeling much better now." What should the nurse tell the client? 1. "You have taken your medication long enough so, the primary healthcare provider should discontinue it today." 2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." 3. "I will be required to have you arrested if you do not come back for further treatment." 4. "Just let us decide when you should stop taking the medication."

2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured."

A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.

2. Check current lab values of hematocrit and hemoglobin.

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

2. Fever 3. Dyspnea 5. Wheezing

A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? BP 90/40; HR 125; RR 30 and labored; + jugular venous distention (JVD) with subcutaneous emphysema noted to right shoulder area. 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.

2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen.

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

2. Instructing the client to lean the head back slightly when swallowing.

A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward.

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

2. Pours boiling water from pan into cup of tea5. Prepares and cooks large casserole in oven

The nurse is assessing a client admitted yesterday with a diagnosis of closed head injury and fractured pelvis following a motorcycle accident. Today the nurse observes a small petechial rash on the client's chest. What specific indications of a serious complication should the nurse report immediately to the healthcare provider? 1. An increased blood pressure with tachycardia. 2. A widening pulse pressure with increasing pulse. 3. A petechial rash with an increase in temperature. 4. A rapid respiratory rate with dropping oxygen levels.

3. A petechial rash with an increase in temperature.

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

4. Send client with crutches to physical therapy for evaluation.

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

3. Increase the IV rate of the lactated ringer's solution.

A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first? 1. Perform sterile wound care to lower leg. 2. Start I.V. for administration of antibiotics. 3. Place client on bedrest with left leg elevated. 4. Draw blood for serial cultures and lab work.

3. Place client on bedrest with left leg elevated.

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

3. Prevent respiratory complications.

The nurse manager is making rounds in a long-term care facility and discovers an unfamiliar client standing in the hallway in a puddle of liquid. What is the nurse manager's priority action? 1. Ask client to state name and room number. 2. Find dry clothes and clean client completely. 3. Wipe up puddle of liquid and call housekeeping. 4. Contact unit charge nurse to identify the client.

3. Wipe up puddle of liquid and call housekeeping.

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

4. "I will be able to donate blood when I am well."

A client has received 850 mL of an isotonic solution intravenously in less than 60 minutes. Which central venous pressure (CVP) reading noted by the nurse indicates a problem related to the amount of intravenous fluids infused? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

4. 10 mm of Hg

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

4. Biologically-based therapies.

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

4. Respiratory alkalosis

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

An elderly client with a history of congestive heart failure has been admitted to the Telemetry Unit with new-onset chest pain and palpitations. The healthcare provider decides to change the client's hydralazine to metoprolol. In preparing to teach the client about changes related to the new medication, the nurse is aware that metoprolol will likely decrease chest pain episodes secondary to what known side effect of hydralazine? 1. Dizziness 2. Hypotension 3. Sodium retention 4. Reflex tachycardia

4. Reflex tachycardia

A nurse utilizes the Braden Scale to assess and document the pressure sore risk of a client diagnosed with Guillain-Barré syndrome. Based on this documentation, what score should the nurse assign to this client?

Braden Scale score of 13