NCLEX Question Trainers

A client has a nasogastric tube connected to low intermittent suction. At 0700 the nurse documents 235 mL of greenish drainage in the suction container. At 1500 there is 445 mL of greenish drainage. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the NG tube for 0700-1500? 1) 150 mL 2) 210 mL 3) 295 mL 4) 385 mL

1 445-235= 210-60= 150

The parent of the 7-year-old child is dying. The nurse anticipates the child will have which concept of death? 1) Death is punishment for the child's actions. 2) Death is inevitable and irreversible. 3) Death is temporary and gradual. 4) Death as a concept based on past experience.

1 7 year olds see death as punishment 2: by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible 3: is a preschool child's concept of death 4: adolescent concept of death

The nurse cares for the male client diagnosed with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. Which statement best describes the rationale for doing these tests? 1) These tests are valuable screening tests for prostatic cancer. 2) The level of PSA is decreased in clients with renal calculi. 3) The tests reflect the level of renal involvement in acid-base problems. 4) The level of PSA is elevated in clients in early-stage kidney failure.

1 PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value 2, 3, 4: inaccurate information about a PSA

At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement? 1) The results will inform us of the baby's size. 2) This test will evaluate the baby's lungs. 3) The test will show us if there is any problem in the baby's genes. 4) Early problems with the baby's blood can be identified with this test.

1 US detects the size, growth patterns, and gestational age. 2: determined with L/S ratio by an amniocentesis 3 and 4: determined with an amniocentesis

The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis? 1) The leg appears to be shortened and is adducted and externally rotated 2) Plantar flexion is observed with sciatic pain radiating down the leg 3) From the hip, the leg appears to be longer and is externally rotated 4) There is evidence of paresis with decreased sensation and limited mobility

1 accurate assessments of the position of a fractured hip prior to repair 2: plantar flexion occurs with foot drop 3: leg would not appear to be longer 4: occurs with injury to the lumbar disc area

The child has a closed transverse fracture of the right ulna. Which nursing action before the application of a cast is most important? 1) Check the radial pulses bilaterally and compare. 2) Evaluate the skin temperature and tissue turgor in the area. 3) Assess sensation of each foot while the child closes the eyes. 4) Apply baby powder to decrease skin irritation under the cast.

1 assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness 2: assessment; temperature indicates decreased circulation but is subjective and not most important 3: assessment; upper (not lower) extremity fracture 4: implementation; should not be done because it would increase skin irritation

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1)The surface of the tongue 2) Hemoglobin and hematocrit 3) Skin surfaces in skin folds 4) Changes in urine characteristics

1 cephalosporin, LT use can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended 2, 3, 4: does not reflect a problem with this medication

The client with bipolar illness is extremely angry. The client tells the nurse, "I just found out my spouse has filed for divorce. I need to use the phone right now!" Which action by the nurse is most appropriate? 1) Allow the client to use the phone. 2) Confront the client about the anger and inappropriate plan of action. 3) Do not allow the client to use the phone because this is an involuntary admission. 4) Set limits on the client's phone use because of the inability to control behavior.

1 client is able to use phone unless otherwise indicated by court order or health care provider's order 2: has not lost civil right to use phone 3: denies patient his civil rights 4: inappropriate

The nurse cares for the client with ataxia. Which action is most important? 1) Supervise ambulation 2) Measure the intake and output accurately 3) Consult the speech therapist 4) Elevate the foot of the bed

1 client's coordination is poor; the only relevant nursing action is to supervise ambulation 2: unnecessary 3 and 4: not relevant

The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best? 1) Clomiphene citrate induces ovulation by changing hormonal effects on the ovary. 2) Changes the uterine lining to be more conducive to implantation 3) Alters the vaginal pH to increase sperm motility 4) Produces multiple pregnancy for those who desire twins

1 clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum 2 and 3: infertility problem, but clomiphene citrate does not affect it 4) not a desired effect

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1) The colostomy needs to be irrigated at the same time every day 2) Irrigate the colostomy after meals to increase peristalsis 3) Insert the catheter about 10 inches into the stoma 4) The solution should be very warm to increase dilation and flow

1 colostomy irrigation should be done at the same time each day to assist in establishing a normal pattern of elimination 2: colostomy should be irrigated once a day 3: catheter should never be inserted more than 4 inches 4: solution should be at body temperature; increasing the temp does not make irrigation more effecient

The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? 1) Blood dyscrasia and extrapyramidal symptoms 2) Hearing loss and unsteady gait 3) Nystagmus and vertical gaze palsy 4) Alteration in level of consciousness and increased confusion

1 major adverse effects include hematologic problems, primarily blood dyscrasia and EPS 2, 3, 4: not seen with haloperidol

The HCP orders chlorpromazine to control the alcoholic client's restlessness, agitation, and irritability following surgery. The nurse checks the order with the HCP because of which rationale? 1) The nurse believes the client's symptoms reflect alcohol withdrawal 2) The nurse does not know if the client is allergic to this medication 3) The nurse knows the client is not psychotic 4) The nurse routinely checks on the HCP orders

1 medication is contraindicated for the treatment of alcohol withdrawal symptoms; will lower client's seizure threshold and BP, causing potentially serious medical consequences 2, 3, 4: not best rationale for checking with HCP about this order

The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? 1) Milk 2) Water 3) Orange juice 4) Fruit punch

1 milk contains calcium; calcium binds to lean and inhibits its absorption 2, 3, 4: good for fluid replacement, does not relate to the lead poisoning

The nurse prepares the client for an IV pyelogram (IVP) scheduled in 2 hours. The nurse contacts the HCP if the client makes which statement? 1) I take metformin for type 2 diabetes. 2) I completed the bowel prep last evening. 3) I ate a light meal last evening. 4) I had an IVP 3 years ago.

1 should discontinue 48 hours prior to procedure, contrast media can cause life-threatening lactic acidosis 2: appropriate action; remove feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured 3: appropriate action 4: no reason to contact the HCP

The nurse reviews client assignments on a medical surgical unit. The nurse determines the assignment is appropriate if the nursing assistive personnel provides care for which client? 1) The client diagnosed with AIDS dementia complex and who requires a urine specimen. 2) The client reporting postoperative pain after repair of a torn rotator cuff. 3) The client diagnosed with GI bleeding due to a duodenal ulcer and who is receiving packed cells. 4) The client diagnosed with type 1 diabetes and who is receiving prednisone for a herniated disk.

1 standard, unchanging procedure 2, 3, 4: assign to the RN

The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2° F (39° C) and frequent vomiting. The nurse expects to find which reflex? 1) Babinski reflex. 2) Moro reflex. 3) Tonic neck reflex. 4) Grasp reflex.

1 stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex; disappears after 1 year of age 2: sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape; disappears after 3 to 4 months 3: when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3 to 4 months 4: touching palms of hands or soles of feet causes flexion of hands and toes; palmar grasp disappears after 3 months of age, plantar grasp lessens by 8 months of age

The 6-month-old infant has had all of the required immunizations for that age. The nurse knows this includes which immunizations? 1) Three doses of diphtheria, tetanus, and pertussis vaccine. 2) Measles, mumps, and rubella vaccine. 3) One dose of rotavirus. 4) Varicella vaccine.

1 the first dose of the DTaP may be given at 2 months of age; the second is given around 4 months ; third given around 6 months 2: MMR given at 12-15 months 3: rotavirus is given at 2, 4, and 6 months 4: varicella is given at 12-15 months

A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the client's nutrition? 1) To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2) The client will be unable to maintain any oral intake as long as the tracheotomy is in place. 3) Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4) Because the client is dependent on the ventilator, nutritional intake will be delayed.

1 tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area 2: although client has permanent tracheotomy, will be able to eat normally after area has healed 3: nutritional intake will begin when bowel sounds return and client can tolerate intake 4: client is not dependent on ventilator

The nurse plans a diet for the child diagnosed with cystic fibrosis (CF). Which dietary requirements are considered by the nurse? Select all that apply. 1) High-protein. 2) Low-sodium. 3) High-calorie. 4) Low-protein. 5) Low-carbohydrate. 6) High-sodium.

1 and 3 impaired intestinal absorption due to cystic fibrosis necessitates a diet high in protein and calories 2: no need to reduce sodium 4: need high protein for growth and because of loss of nutrients 5: the level of carbohydrate is not as important as increased calories 6: sodium should not be elevated

The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. In which order does the nurse address these situations? 1) The client diagnosed with depression says to the nurse, "My plan is complete and I'm ready to go." 2) The client with substance abuse reports harassment by another client. 3) The client diagnosed with schizophrenia tells the nurse the TV should be destroyed. 4) The client diagnosed with bipolar disorder walks into the day room wearing only underwear.

1, 2, 3, 4 1: the client diagnosed with depression could indicate impending suicide; requires immediate follow-up 2: the client with substance abuse should be removed to quiet area, decrease environmental stimuli; may cause distraction for other clients 3: the client diagnosed with schizophrenia is experiencing command hallucination; protect from injury and destroying the TV 4: the client wearing only underwear is not a harm to self or others initially

The client is receiving imipramine. It is most imporatant for the nurse to instruct the client to immediately report which symptoms? 1) Fever 2) Dry mouth 3) Increased fatigue 4) Vomiting and diarrhea 5) Staggering gait 6) Sore throat

1, 2, 3, 4, 6 imipramine is a tricyclic antidepressant; side effects include hyperthermia, dry mouth, increased fatigue, N/V/D, and sore throat 5: staggering gait is not a side effect of this medication

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client? 1) Hypotension 2) Low back pain 3) Wet breath sounds 4) Fever 5) Urticaria 6) Severe shortness of breath

1, 2, 4 client with a hemolytic transfusion reaction will experience a drop in blood pressure, low back pain, and an elevated temperature 3: wet breath sounds occur due to circulatory overload; manifestation is not expected for the client 5: aka hives-expected for client experiencing an allergic reaction 6: aka dyspnea- expected for a client experiencing circulatory overload

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? 1) Tremors 2) Elevated temperature 3) Depression 4) Nocturnal leg cramps 5) Night sweats 6) Decreased concentration

1, 2, 4 symptoms of withdrawal 3: seen in depressed client 5: seen with TB, leukemia, or other infections 6: seen in depressed client

The nurse receives report from the previous shift. In which order should the nurse see these clients? Place answers in order of priority. 1) The client 1 day postoperative with an epidural catheter in place. 2) The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400. 3) The client diagnosed with cardiomyopathy being evaluated for a heart transplant. 4) The client post coronary artery bypass graft having the atrioventricular wires removed at 1500.

1, 3, 2, 4 1: most unstable client with epidural needs assessment for side effects of epidural and is fresh postop respiratory consideration. 3: client needing heart transplant will be unstable requires monitoring and early assessment; circulation consideration. 2: needs assessment of blood glucose and preoperative needs but falls behind respiratory and unstable circulation. 4: stable client.

The nurse cares for the elderly client diagnosed with dementia. Which nursing action is best? 1) Place the client in soft hand restraints or chair restraints. 2) Monitor wandering behaviors during a 7-day period. 3) Keep the lounge's television volume on a low level. 4) Encourage a diet high in protein, iron, and vitamins.

2 appropriate assessment to determine if client wanders during specific times of the day; assess before implementing 1: do not restrain unless all other options have been exhausted 3: need to prevent sensory overload; should assess first 4: offer well-balanced diet

The client was just placed in physical restraints. Which nursing intervention is most important for the client's care? 1) Prepare PRN dose of psychotropic medication 2) Check that the restraints have been applied correctly 3) Review hospital policy regarding duration of restraints 4) Monitor the client's needs for hydration and nutrition while restrained

2 assessment; while a client is restrained, physiological integrity is important; monitoring position, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained 1: implementation- inappropriate for the client in restraints 3: implementation- all staff members involved in a restraint event must be aware of hospital policy before using restraints 4: assessment- important to attend to client's nutrition and hydration after the client is safely restrained

The nurse cares for the multipara client who delivered an infant 1 hour ago. The nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2 cm below the umbilicus, and there is moderate lochia rubra. It is most important for the nurse to take which action? 1) Perform a straight catheterization. 2) Offer the client the bedpan. 3) Put the baby to breast. 4) Massage the uterine fundus.

2 boggy uterus deviated to right indicates full bladder, encourage client to void 1: encourage the client to void before catheterizing 3: will increase uterine tone, but the problem is a full bladder 4: findings indicate a full bladder

The nurse cares for the client diagnosed with Meniere's syndrome. The nurse stands directly in front of the client when speaking. Which best describes the rationale for the nurse's position? 1) This enables the client to read the nurse's lips. 2) The client does not have to turn the head to see the nurse. 3) The nurse will have the client's undivided attention. 4) There is a decrease in client's peripheral visual field

2 by decreasing movement of client's head, vertigo attacks may be decreased 1: client is not hard of hearing 3: not the reason 4: there is no problem with visual fields

The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1) Low blood pressure and weight loss 2) Thin extremities with easy bruising 3) Decreased urinary output and decreased serum potassium 4) Tachycardia with reports of night sweats

2 clients with Cushing syndrome tend to lose weight in their legs and have petechia and bruising 1: BP increased and client gains weight 3: no correlation with urinary output; potassium decreases 4: no correlation with syndrome

A client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2.5 x 10^3/mm^3, RBC 5.1 x 10^6/mm^3, total serum calcium 9.3 mg/dL. On the basis of the lab values, the nurse determines which is the priority nursing diagnosis? 1) Activity intolerance 2) Infection 3) Anxiety 4) Dehydration

2 clients with a low WBC count are susceptible to infection 1 and 4: not a priority for this client 3: although it might be of concern, infection is a greater priority

The nurse cares for the client on suicide precautions. The client verbalizes other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on this data, which nursing action is most appropriate? 1) Recommend the health care provider decrease the client's medication dosage. 2) Recommend the treatment team reevaluate the client's treatment plan. 3) Give the client privileges to walk around the hospital alone. 4) Ask the family to begin planning for the client's discharge.

2 data suggest the client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture 1: may reverse the client's progress 3: may be the team's decision, but not until a thorough review of the case is completed 4: premature

Which observation suggests to the nurse the client has developed an Addisonian crisis? 1) Muscular weakness and fatigue 2) Restlessness and rapid, weak pulse 3) Dark pigmentation of the skin 4) GI disturbances and anorexia

2 may be signs of shock r/t Addisonian crisis 1, 3, 4: signs and symptoms of Addison's disease, but do not indicate a crisis

The nurse plans care for the 20-year-old client. Which psychosocial stage does the nurse identify as the priority to consider? 1) Identity versus identity diffusion 2) Intimacy versus isolation 3) Integrity versus despair and disgust 4) Industry versus inferiority

2 this is the stage for 19-35 year olds 1: appropriate for adolescents 3: for 65 years and older 4: for 6-12 years of age

The nurse cares for a client admitted 2 days ago with a diagnosis of a closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? 1) Glucosuria 2) Cracked lips 3) Weight gain of 5 lb. 4) BP 160/90, pulse 56 5) Urinary output of 4L/24 hours 6) Urine specific gravity of 1.004

2, 5, 6 1: occurs with diabetes mellitus 2: due to dehydration caused by excessive water loss 3: weight loss occurs; symptom of SIADH- opposite of diabetes insipidus 4: late signs of increased ICP or brain damage 5: excessive fluid loss is major occurrence of DI 6: specific gravity very low as urine is not concentrated in the kidney

The nurse provides care for a 2-day-old client. The neonate will not take formula from the parent or the nurse. Which is the priority nursing diagnosis? 1) Swallowing difficulty. 2) Failure to thrive. 3) Dehydration. 4) Altered bonding.

3 the priority is fluid volume for a neonate 1: no information about swallowing provided in the stem 2: failure to thrive is impaired growth fluid volume is of greater concern 4: no information about bonding provided in the stem

The nurse is discussing growth and development with parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group? 1) Solitary play 2) Parallel play 3) Associative play 4) Aggressive play

3 1: describes play for an infant 2: describes play for a toddler 4: is not play but a behavior

The nurse cares for the client receiving a blood transfusion for approximately 30 minutes. Which symptom indicates a severe allergic reaction is occurring? 1) Bounding peripheral pulses 2) Chills 3) Respiratory wheezing 4) Lower back discomfort

3 allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema 1: seen with circulatory overload; severe anaphylactic reaction may cause hypotension 2: indicative of a hemolytic or febrile transfusion reaction 4: indicative of a hemolytic transfusion reaction

The nurse cares for the client after right cataract surgery. The nurse intervenes if which observation is made? 1) Client is in the supine position. 2) The head of the bed is elevated 30 degrees. 3) The client is lying on the right side. 4) An eye shield is over the right eye.

3 client should not be positioned with operative side in a dependent position or against the bed 1: appropriate position 2: decreases swelling and pain 4: shield is appropriate

The nurse assesses the client's neurosensory cerebellar functioning. Which assessment technique is correct? 1) Test the client's deep tendon reflexes to observe for weakness. 2) Check the client's pupils with a penlight and observe for constriction. 3) Have the client stand with eyes closed and observe for swaying. 4) Ask the client to show the teeth and stick out the tongue.

3 coordination is governed by the cerebellum; this test evaluates neurosensory status 1: general central nervous system response, not sensory involvement 2: evaluates for increased intraocular pressure 4: evaluates the facial and hypoglossal nerves

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? 1) The client has an allergy to shellfish 2) The client has diminished palpable peripheral pulses 3) The client has cool lower extremities bilaterally 4) The client is anxious about the pending procedure

1 allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure 2, 3, 4: may be normal finding before the test

The client is diagnosed with an adjustment disorder with depressed mood. The client has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1) During the morning hours 2) During the middle of the day 3) During the afternoon hours 4) During the evening hours

1 client with reactive depression has the highest level of physical and psychic energy in the morning 2, 3, 4: as the day progresses, energy level declines

The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents? 1) Adequate protein, low sodium intake 2) Low protein, low potassium intake 3) Low potassium, low calorie intake 4) Limited protein, high carbohydrate

1 if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted 2: low protein contraindicated in clients with kidney disease 3: does not address protein need at all 4: may be appropriate only if the child cannot tolerate protein intake

The nurse cares for the client diagnosed with a recurrent urinary tract infection. The health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? 1) Milk 2) Cranberry juice 3) Water 4) Tea

1 should limit intake of alkaline foods and fluids 2: can be increased to acidify urine 3 and 4: does not need to be restricted

The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? 1) Sodium 2) Protein 3) Potassium 4) Iron

1 alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity 2, 3, and 4: doesn't interact with lithium

Under the supervision of the RN, a student nurse changes the dressing of the client with a newly inserted peritoneal dialysis catheter. In which order does the RN expect the student to perform this procedure? 1) Remove old dressing using clean gloves 2) Apply providone-iodine to sterile cotton swabs 3) Clean the insertion site using a circular motion from the insertion site outward 4) Apply two sterile precut 4x4s to the catheter insertion site 5) Securely tape the edges of the sterile dressing with paper tape

1, 2, 3, 4, 5

The client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which nursing assessment finding supports this diagnosis? Select all that apply. 1) Buffalo hump. 2) Intolerance to heat. 3) Hyperglycemia. 4) Hypernatremia. 5) Intolerance to cold. 6) Irritability.

1, 3, 4 hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections 2: indication of hyperthyroidism 5: indication of hypothyroidism 6: indication of hypoparathyroidism

The nurse recognizes which symptoms are early signs of lithium toxicity? 1) Fine motor tremors 2) Involuntary muscle movements 3) Seizures 4) Nausea and vomiting 5) Orthostatic hypotension 6) Diarrhea

1, 4, 6 2: associated with antipsychotics 3: associated with severe lithium toxicity 5: associated with antipsychotics

The nurse cares for a client with a diagnosis of Guillain-Barré syndrome. Which symptoms support this diagnosis? Select all that apply. 1) Respiratory failure. 2) Pulmonary congestion. 3) Hypertension. 4) Flaccid paralysis. 5) Hemiplegia. 6) Urinary retention.

1, 4, 6 classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation 2: not a symptom 3: not a symptom, may have hypotension 5: paralysis is whole body, not one sided as in CVA

The nurse cares for a client receiving decussate 100 mg through a gastric tube. The solution contains 150 mg/ 15 mL. The nurse should administer how many mLs of the solution to the client?

10 mL

The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics? 1) An infant LGA, craniofacial abnormalities, and hydrocephalus 2) Small head circumference, low birth weight, and underdeveloped cheekbones 3) large head circumference, low birth weight, excessive rooting and sucking behaviors 4) normal head circumference, low birth weight, respiratory distress syndrome

2 3: may have feeding difficulties and poor sucking ability 4: RDS related to preterm birth, neurologic damage, small trachea, floppy epiglottis

The client has a neurologic disorder. Which nursing assessment is most helpful to determine subtle changes in the client's level of consciousness? 1) Client posturing. 2) Glasgow coma scale. 3) Client thinking pattern. 4) Occurrence of hallucinations.

2 GCS score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses 1: indicates increased ICP 3 and 4: more appropriate for the psychiatric client

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? 1) SIDS will provide you with this opportunity 2) SHARE... 3) RESOLVE 4) CANDLELIGHTERS

2 SHARE is a support group for parents who have lost a newborn or have experienced miscarriage 1: support group for parents who have had an infant die from sudden infant death syndrome 3: support group for infertile clients 4: support group for families who have lost a child to cancer

The infant is admitted with vomiting and diarrhea. The infant's anterior fontanelle is depressed and the temperature is 103.2° F (39.5° C). Which nursing action is most appropriate? 1) Obtain daily weights and evaluate weight loss. 2) Observe the infant's ability to take in fluids. 3) Place a full bottle of pediatric electrolyte solution at the bedside. 4) Start an intravenous infusion.

2 assessment; will assist in determining if hydration can be done through oral fluids alone 1: assessment; correct information, but is not what the question asks for 3: implementation; does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee the infant is taking fluids 4: implementation; would be implemented later

The nurse cautions the client with hypothyroidism to avoid which implementation? 1) Warm environmental temperatures 2) Narcotic sedatives 3) Increased physical exercise 4) A diet high in fiber

2 client is very sensitive to narcotics barbiturates, and anesthetics 1: client with hypothyroidism cannot tolerate cold temperatures 3: should not be avoided 4: requires high fiber, high cellulose foods to prevent constipation

Which type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism? 1) Foods high in phosphorus 2) Foods high in calcium 3) Foods low in sodium 4) Foods low in potassium

2 diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance 1: diet should be low in phosphorus; hypoparathyroidism is decreased secretion of PTH; indications include tetany, muscular irritability carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm 3 and 4: not regulated by the parathyroid

The adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse includes which information in the preoperative teaching session? 1) Explain that the client will walk with a prosthesis soon after surgery. 2) Encourage the client to share feelings and fears about the surgery. 3) Take the informed consent form to the client and ask the client to sign it. 4) Evaluate how the client plans to complete schoolwork during hospitalization.

2 discussing client's feelings and fears is important in dealing with anxiety due to change in body image and functioning 1: falls to recognize client's immediate concerns 3: client is underage; parents will need to sign the permit 4: is more appropriate for the postoperative period of time than for the preoperative period

The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1) Offer the infant only clear liquids 2) Make the infant NPO for 3 hours 3) Feed the infant regular formula 4) Maintain the infant NPO for 6 hours

2 infant should be NPO 3 hours prior to the procedure 1 and 3: inappropriate 4: unnecessary for an infant to be NPO for 6 hours

The client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client is diagnosed with a spinal cord injury at the level of C4. The client is tearful, constantly reports discomfort, and requests to be suctioned. The nurse understands the client's attention-seeking behaviors may be due to which feelings? 1) Anger and frustration. 2) Awareness of vulnerability. 3) Increased social isolation. 4) Increased sensory stimulation.

2 is experiencing an increased awareness of physical vulnerability due to the spinal cord injury; fosters increased dependency needs that are real due to the injury; is trying to determine who is consistent and trustworthy for meeting significant physical needs 1, 3, 4: not accurate for situation

The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects? 1) Photosensitivity and constipation 2) Hypotension and respiratory depression 3) Tardive dyskinesia and diplopia 4) Dry mouth and tinnitus

2 narcotic analgesic used for moderate to severe pain, monitor VS frequently

The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1) Abnormal body proportions 2) Early sexual maturation 3) Delicate features 4) Course, dry skin

3 appear younger than chronological age 1: see small size but normal body proportions 2: usually have delayed sexual maturity 4: usually see fine, smooth skin

The client has an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L (3.0 mmol/L). The client has digoxin ordered. Which nursing action is best? 1) Give the digoxin. 2) Hold the digoxin. 3) Notify the health care provider. 4) Recheck the pulse.

3 hypokalemia can precipitate digoxin toxicity; HCP should be called to obtain order for potassium supplement 1: although the pulse is normal, level of potassium must be considered 2: notify health care provider about low potassium 4: notify health care provider about the potassium level

The health care provider diagnoses Graves' disease for the client. The nurse expects the client to exhibit which symptom? 1) Lethargy in the early morning 2) Sensitivity to cold 3) Weight loss of 10 lb in 3 weeks 4) Reduced deep tendon reflexes

3 increased metabolic rate causes weight loss even with increased appetite 1: will be restless 2: will have heat intolerance due to increased metabolic rate 4: reflexes will be hyperactive

The adult client receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the HCP? 1) PT 12 seconds and Hgb 15 g/dL 2) BUN 18 mg/dL and creatinine 1.0 mg/dL 3) Serum K 3.4 mEq/L and serum Ca 7.8 mg/dL 4) AST 18 U/L and ALT 12 U/L

3 normal K 3.5-5.0 and normal Ca 8.5-10.5 mg/dL; indicates hypokalemia and calcemia 1: normal PT 9.5-12 seconds, normal Hgb male 13-18 female 12-16 g/dL 2: normal BUN 10-20 mg/dL for 60 years or younger, normal creatinine 0.7-1.4 mg/dL 4: normal AST and ALT 8-40 units

The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? 1) Blurred vision and proteinuria 2) Epigastric pain and headache 3) Facial swelling and proteinuria 4) Polyuria and hypertonic reflexes

3 represents 2/3 symptoms seen with pre-eclampsia, also includes HTN 1: only partially correct; blurred vision appears later, with eclampsia 2: contains signs of eclampsia before a seizure 4: oliguria is seen later with eclampsia

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis? 1) Social interaction impairment 2) Potential activity intolerance 3) Powerlessness 4) Difficult with coping

4 client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is inability to cope 1, 2, 3: not warranted with the data indicated

The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the health care provider? 1) Headache. 2) Disruption in short- and long-term memory. 3) Transient confusional state. 4) Backache.

4 client undergoing ECT needs to be instructed about what could be experienced during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the health care provider 1, 2, 3: expected effect

Which action is the best way for the nurse to assess the fluid balance of an elderly client? 1) Assess the client's blood pressure 2) Check the client's tissue turgor 3) Determine if the client is thirsty 4) Maintain an accurate intake and output

4 best indicator of fluid status 1: may be elevated because of age-related hypertension 2: not accurate because of changes in skin elasticity due to the aging process 3: not reliable indicator; may have diminished sensation of thirst

The nurse cares for the client receiving D5 0.45% NS 1,000 mL to run from 0900-1700. The drip factor on the delivery tubing is 20 gtt/mL. At what rate does the nurse set the IV to drip? Round to nearest whole number (gtt/min)

42 gtt/min

During the mother's fourth stage of labor, the nurse palpates the client's fundus in which location? (click on image)

Uterus is normally contracted and palpable at the umbilicus

A client returns from surgery after a right mastectomy. An IV of 0.9% NS is infusing at 100 mL/hour into the lower portion of the left forearm. The IV infiltrates several hours later. The nurse supervises the student nurse preparing to insert a new peripheral IV catheter. The nurse intervenes in which situation? 1) A site is selected with soft, elastic veins 2) A site is selected distal to the site of infiltration on the left arm 3) A site is selected close to the wrist joint 4) The skin is held taut prior to insertion of the catheter

3 inappropriate site because it is further down on the forearm, and movement in area could cause displacement. The chosen site must be higher up on the arm. 1: acceptable site selection 2: the new site needs to be away from the infiltrated site, higher up on the arm; site may be used if the same extremity must be used (in this case, right extremity must be avoided because of the mastectomy) 4: holding the skin taut helps the needle insertion during the procedure

The elderly client diagnosed with chronic schizophrenia is cared for in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation includes which finding? 1) Assessment of ADL (self-care) ability. 2) Mini-Mental Status Examination (MMSE). 3) Abnormal Involuntary Movement Scale (AIMS). 4) Modified Overt Aggression Scale (MOAS).

3 most widely accepted examination to test for the presence of tardive dyskinesia 1: assessment of client's abilities to complete the activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill but not related to tardive dyskinesia 2: measures cognitive function 4: assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population

The client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1) Guarantees secure placement of the tracheostomy tube in the airway. 2) Prevents ischemia of the tracheal wall by distributing the 3) Decreases the chance of aspiration into the trachea. 4) Protects the trachea from ischemia and edema.

3 seals trachea, helps to prevent aspiration 1: inaccurate, not the purpose of the cuff on a tracheostomy tube 2: complication of using a cuffed tracheostomy tube 4: trauma from overinflated tube may cause edema

The nurse obtains a history from the parent of the 6-year-old child with a history of epilepsy. The child was admitted with uncontrolled seizures. It is most important for the nurse to ask which question? 1) "What part of the body was affected by the seizure?" 2) "What is the family history of seizure disorders?" 3) "What was your child doing before the seizure?" 4) "How long has it been since the last episode of seizures?"

3 seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, medications) 1: not most important question 2: should be included in detailed history, but will not prevent an immediate recurrence 4: should be included in detailed history, but will not prevent an immediate recurrence

The nurse checks the incision of the client 48 hours after surgery for a hernia repair. Which finding indicates a possible complication? 1) There is swelling under the sutures. 2) There is crusting around the incision line. 3) The incision line is red. 4) The incision line is approximated.

3 should be pink, not red; indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage 1: slight swelling is expected during healing 2: slight crusting of incision line is normal 4: shows healing is taking place

The client experiences inflammation due to rheumatoid arthritis. Which nursing statement is correct? 1) "If you are having a 'bad' day, postpone your exercises until the next day." 2) "Passive exercises are better for you than active exercises." 3) "When inflammation is severe, decrease the number of repetitions of the exercise." 4)"You can substitute your normal household tasks for your exercises to provide variety."

3 should reduce repetitions when client experiences more pain 1: consistency is important to maintain joint mobility 2: active exercises are better than passive or active-assistive exercises 4: should do exercises that have been prescribed for client

The adult client is admitted to the hospital unit diagnosed with hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1) Contact precautions. 2) Airborne precautions. 3) Standard precautions. 4) Droplet precautions.

3 standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal I; incontinence 1: required with client care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the client's environment 2: unnecessary; used with pathogens transmitted by airborne route 4: unnecessary; used when pathogens transmitted by infectious droplets

The parent of a child with chickenpox asks the clinic nurse who the child will not come down with chickenpox again if exposed to the virus at school at later date. Which explanation does the nurse give? 1) Natural passive immunity occurs because the child receives antibodies from outside the body 2) Artificial active immunity occurs because the child receives specific antigens against the chickenpox virus 3) Natural active immunity occurs because the child's body active makes antibodies against the chickenpox virus 4) Artificial passive immunity occurs because of the inflammatory process of chickenpox

3 antigen enters the body without human assistance, body responds by actively making antibodies 1: occurs when antibodies are passed from mother to fetus via placenta, colostrum, and breast milk 2: small amounts of specific antigens are used for vaccination; body responds by actively making antibodies 4: involves injection with antibodies that were produced in another person or animal; used to protect person exposed to serious disease

Which assessment information indicates to the nurse the client has hypocalcemia? 1) Constipation 2) Depressed reflexes 3) Decreased muscle strength 4) Positive Trousseau's sign

4 indicative of neuromuscular hyperreflexia associated with hypocalcemia 1, 2, and 3: symptoms associated with hypercalcemia

The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1) Darker skin that is more pigmented 2) Skin that is ruddy and oily 3) Skin that is puffy and scaly 4) Skin that is pale and dry

1 increase in melanocyte-stimulating hormone results in "eternal tan" 2, 3, and 4: not seen with Addison's disease

The nurse cares for the client with dementia. Which plan of care is most successful? 1) Teach new skills for adjusting to the aging process. 2) Adjust the environment to meet the client's individual needs. 3) Encourage competitive activities to keep the client physically strong. 4) Provide unstructured activities with frequent changes to increase stimulation

2 client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability 1: unable to learn new skills 3 and 4: requires skills the client with dementia does not have

The 4-year-old child is admitted with drooling and an inflamed epiglottis. The nurse identifies which symptom as indicative of an increase in respiratory distress? 1) Bradycardia 2) Tachypnea 3) General pallor 4) Irritability

2 increase in the RR is an early sign of hypoxia, also for tachycardia 1: occurs early in hypoxia 3: not specific for hypoxia 4: client may be anxious and restless, but is generally not described as irritable

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1) Anal sphincter 2) Abdominal 3) Trapezius 4) Rectus femoris

2 strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine 1, 3, 4: does not contribute to support of the lumbar spine

In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior? 1) Acceptance 2) Bargaining 3) Anger 4) Depression

3 1: fifth stage 2: third stage 4: fourth stage

The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation most likely indicates bulimia? 1) Edema of the lower extremities 2) The presence of lanugo 3) Ulcerated oral mucous membranes 4) Dry, yellowish colored skin

3 due to frequent vomiting 1: common with anorexia 2: seen with lanugo 4: bulimics are normal in appearance

The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action? 1) No special actions are necessary 2) Wear a double mask and gloves 3) Perform good hand washing 4) Wear a gown and mask

3 good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients 1, 2, 4: inaccurate, masks are unnecessary for this client

The nurse cares for the client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1) The client is anxious and restless. 2) There is a small amount of dark drainage on the dressing. 3) The client reports persistent pain at the operative site. 4) The skin is cool above the operative site.

3 pain is characteristic of inflammation and infection 1: may be due to changes in body image or pain 2: expected, not indicative of an infection 4: warm skin above the operative site would indicate infection

The client takes phenelzine. The nurse observes the client eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1) Buspirone. 2) Fluoxetine. 3) Prochlorperazine. 4) Nifedipine.

4 antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; adverse effects include dizziness, headache, nervousness 1: antianxiety; adverse effects include light-headedness, confusion, hypotension, palpitations 2: SSRI antidepressant; adverse effects include palpitation, bradycardia, nausea and vomiting 3: antiemetic; adverse effect include drowsiness, orthostatic hypotension

The nurse identifies which finding has the greatest impact on the elderly client's ability to complete ADLs. 1) Perseveration 2) Aphasia 3) Mnemonic disturbance 4) Apraxia

4 loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly 1, 2, 3: speech disturbance, which would have the greatest impact on communication ability

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? 1) 200 2) 300 3) 400 4) 500

4 milk production requires an increase of 500 calories per day 1, 2, 3: inadequate amount

The nurse teaches nutrition classes at the community center. Which food does the nurse encourage the low-income client to eat to satisfy essential protein needs? 1) Legumes. 2) Red meat. 3) Seafood. 4) Cheese.

1 legumes are an economical source rich in protein 2, 3, 4: high in protein, but more expensive to purchase

The nurse cares for the client receiving a continuous tube feeding. Which nursing action is most appropriate? 1) Rinse the bag and change the formula every 4 hours. 2) Rinse the bag and change the formula every shift. 3) Rinse the bag and change the formula every 12 hours. 4) Rinse the bag and change the formula every 2 hours.

1 there is an increased growth of organisms after 4 hours 2 and 3: inappropriate due to increased organism growth 4: not a necessary action to maintain asepsis

The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first? 1) Instructs the significant other about the medication regimen 2) Determines the client's comprehension of the medication administration 3) Prepackages the medication to encourage correct administration 4) Encourages a return demonstration of medication self-administration

2 assessment; intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdose and underdose 1 and 3: implementation; might be done after assessment of the comprehension level 4: might be done after evaluation of comprehension level

The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV? 1) Provide a route for pain medications 2) Maintain fluid balance 3) Prevent gastrointestinal upset 4) Obtain blood specimens for analysis

2 loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement 1: route used for pain medication to ensure absorption, but not primary purpose of IV 3: threat of gastrointestinal upset not primary importance; IV's primary purpose to maintain fluid and electrolyte balance 4: peripheral IV not used for this purposeThe

The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool-aged child. After the cast is applied, the nurse takes which action first? 1) Petals the edges of the cast to prevent irritation. 2) Elevates the child's left arm on two pillows. 3) Applies cool, humidified air to dry the cast. 4) Asks the client to move the fingers to maintain mobility.

2 minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast 1: done when cast is completely dry, prevents crumbling of plaster into cast 3: would delay drying of cast 4: maintaining mobility of fingers not most important after application of cast

The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for the client. Which result indicates the tube feeding can begin? 1) A small amount of white mucus is aspirated from the NG tube. 2) The contents aspirated from the NG tube have a pH of 3. 3) No bubbles are seen when the nurse inverts the NG tube in water. 4) The client says the NG tube can be felt in the back of the throat.

2 stomach contents are acidic 1: mucus may be from the lungs 3: not a safe way to check placement 4: not a reliable indication

The nurse reviews procedures with the health care team. The nurse intervenes if the RN staff member makes which statement? 1) It is my responsibility to ensure the consent form has been signed and is attached to the client's record. 2) It is my responsibility to witness the signature of the client before surgery is performed. 3) It is my responsibility to explain the surgery and ask the client to sign the consent form. 4) It is my responsibility to answer questions the client may have before surgery.

3 HCP should provide explanation and obtain client's signature 1: describes the nurse's responsibility in obtaining consent 2: signature indicates the nurse saw the client sign the form 4: the nurse should answer questions after the HCP has obtained consent

The client is diagnosed with a gastric ulcer. The nurse anticipates the client will experience pain at which time? 1) Two to three hours after a meal 2) During the night 3) Prior to the ingestion of food 4) One-half to 1 hour after a meal

4 pain related to a gastric ulcer occurs about 0.5-1 hour after a meal and rarely at night; is not helped by ingestion of food 1, 2, and 3: feature of a duodenal ulcer

The nursing team consists of one RN, two LPN/LVNs, and three nursing assistive personnel (NAPs). The RN cares for which client? 1) The client with a chest tube who is ambulating in the hall. 2) The client with a colostomy requiring assistance with an irrigation. 3) The client with a right-sided stroke requiring assistance with bathing. 4) The client declining medication to treat cancer of the colon.

4 requires assessment skills of the RN 1 and 2: stable client with an expected outcome; assign to the LPN/LVN 3: standard, unchanging procedure- assign to the NAP

The client is admitted with irritable bowel syndrome. The nurse anticipates the client's history will reflect which information? 1) Pattern of alternating diarrhea and constipation. 2) Chronic diarrhea stools occurring 10 to 12 times per day. 3) Diarrhea and vomiting with severe abdominal distention. 4) Bloody stools with increased cramping after eating.

1 condition is often called spastic bowel disease; no inflammation is present 2 and 3: refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease 4: bloody stools do not occur with IBS

The nurse evaluates the desired client response to diuretic therapy. Which action is the most reliable client measure for the nurse to use? 1) Obtain daily weights 2) Obtain urinalysis 3) Monitor Na+ and K+ levels 4) Measure intake

1 effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights 2: does not relate to the effects of diuretic therapy 3 and 4: important to consider, but is not a priority

The nurse provides care for a client in a psychiatric facility. The client describes seeing snakes on the walls of the room. Which is an accurate nursing diagnosis? 1) Altered sensory perception. 2) Long-term confusion. 3) Impaired coping. 4) Altered interaction.

1 reflects a pattern of altered perception, which is supported by the data that the client is having a hallucination, defined as a sensory perception for which no external stimuli exist 2, 3, 4: not relevant to the data

A client suspects she is pregnant because the last menstrual period began May 8 and ended May 12. Which estimated date of birth (EDB) will the nurse calculate for this client? 1) February 1. 2) February 15. 3) February 19. 4) March 14.

2 When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. For example, May 8 plus 7 days is May 15 minus 3 months is February 15th.

The neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Because the infant's mother is diagnosed with type 1 diabetes, the nurse knows the infant is at greatest risk for developing which problem? 1) Hypovolemia. 2) Hypoglycemia. 3) Hyperglycemia. 4) Cold stress.

2 fetus produces increased insulin to match mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia 1: no change in blood volume for infant of diabetic mother 3: infant would be at risk of hypoglycemia due to increased insulin production 4: thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic mother

The nursing assistive personnel (NAP) reports to the RN that the client with anemia reports weakness. Which nursing response is best? 1) Listen to the client's breath sounds and report back to me 2) Set up the client's lunch tray 3) Obtain a diet history from the client 4) Instruct the client to balance rest and activity

2 standard, unchanging procedure; decreases cardiac workload 1: requires assessment- should be performed by the RN 3: involves assessment- RN 4: assessment and teaching required; performed by the RN

The nurse assesses orientation to person, place, and time for the elderly hospitalized client. Which principle does the nurse understand? 1) Short-term memory is more efficient than long-term memory 2) The stress of an unfamiliar environment may cause confusion 3) A decline in mental status is a normal part of aging 4) Learning ability is reduced during hospitalization of the elderly client

2 stress of an unfamiliar situation may lead to confusion in elderly 1: just the opposite is true- LT more efficient than ST memory 3 and 4: mental status and learning ability are not affected by aging, although elderly clients may be slower at doing things

The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1) The client puts the right leg on the step, then the cane, followed by the left leg. 2) The client leads with the cane, followed by the right leg and then the left leg. 3) The client advances the right leg, followed by the left leg and the cane. 4) The client puts the cane on the step and advances the left leg, followed by the right leg.

2 to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down 1: to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane 3: should advance cane and weak leg first 4: weaker leg and cane advance first

The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client? 1) Problem with verbal communication 2) Inadequate airway clearance 3) Possible skin integrity impairment 4) Acute pain

2 top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions 1: correct diagnosis but not priority 3: correct diagnosis but not priority 4: tracheostomy is not usually painful

The nurse cares for the client diagnosed with hypoparathyroidism. Which nursing action has the highest priority for this client? 1) Develop a teaching plan 2) Plan measures to deal with cardiac dysrhythmias 3) Take measures to prevent a respiratory infection 4) Assess laboratory results

2 (strategy: ABCs) cardiac dysrhythmias related to low serum calcium would be the highest priority 1 and 4: not highest priority action related to the diagnosis 3: potential for respiratory infection is not a major threat

The nurse receives report on these clients from the previous shift. In which order should the nurse see the clients? 1) The client receiving IV potassium infusion who reports burning at the IV site 2) The client receiving ciprofloxacin IV, reports a fine macular rash on the chest. 3) The client receiving a blood transfusion who reports a dry mouth. 4) The client scheduled to receive heparin and the aPTT is 70 seconds.

2, 1, 4, 3 2: indicates hypersensitivity reaction; should stop medication and notify the health care provider. 1: should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires first attention. 3: lower limit of normal is 20 - 25 sec; upper limit of normal is 32 - 39 sec; aPTT is within therapeutic range; therapeutic levels increase aPTT 1.5 to 2 times control value; should give medication. 4: not an immediate concern; routine transfusion evaluation.

The nurse recognizes which symptoms as characteristic of a panic attack? 1) Decreased blood pressure 2) Palpitations 3) Decreased perceptual field 4) Bradycardia 5) Diaphoresis 6) Fear of going crazy

2, 3, 5, 6 1: blood pressure increases 2: heart rate increases and palpitations occur 3: visual field narrows- part of fight or flight reaction 4: tachycardia occurs 5: neurological changes cause diaphoresis 6: clients fear they are going crazy- part of neuro changes

The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is most likely to reveal which finding? 1) Hyperactive deep tendon reflexes 2) Peripheral neuropathy affecting the hands 3) Disorientation to person, place, and time 4) Impaired concentration and memory loss

3 approx. 65% of AIDS clients demonstrate a progressive dementia staged accordion to severity of debilitation; late stage is typified by cognitive confusion and disorientation 1 and 2: not relevant to this condition 4: is a sign of early-onset dementia

During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which response by the nurse is best? 1) You are nauseated because of the fatigue you are feeling 2) The nausea is due to an increase in the basal metabolic rate 3) The nausea is caused by an elevation in the hormones 4) If you eat different kinds of foods, you won't be nauseated

3 during the first trimester, n/v are related to elevation in estrogen, progesterone, and hCG from the endocrine system 1, 2, 4: describes an erroneous rationale for the nausea

The older client diagnosed with pneumonia is admitted to the medical/surgical unit. Which other client does the nurse place with the older client? 1) The 20-year-old in traction for multiple fractures of the left lower leg. 2) The 35-year-old with recurrent fever of unknown origin. 3) The 50-year-old recovering alcoholic with cellulitis of the right foot. 4) The 89-year-old with Alzheimer's disease awaiting long term care facility placement.

3 generalized nonfollicular infection that involves deeper connective tissue; both clients have infections 1: clients with fractures considered "clean"; don't place with an infectious client 2: don't know the cause of the fever 4: elderly are high risk for developing pneumonia

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1) "The client is unable to complete activities of daily living without assistance." 2) "The client appears to be depressed and anxious regarding impending surgery." 3) "The client constantly calls for nurses and cries uncontrollably." 4)"The family is unable to visit more often than once a week because they live far away".

3 gives an objective description of the client's behavior and affect 1: does not describe emotional adjustment 2: draws conclusions without supporting data 4: describes the client's family, not the client

The client receives parenteral nutrition (PN) for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit which signs and symptoms? 1) Tinnitus, vertigo, blurred vision 2) Fever, malaise, anorexia 3) Diaphoresis, confusion, tachycardia 4) Hyperpnea, flushed face, diarrhea

3 insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination 1 and 4: not seen 2: suggestive of infection

The client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is best? 1) Encourage the client not to do anything without thinking it through very carefully. 2) Explain to the client that anything told to the nurse is kept strictly confidential. 3) Report this to staff members in order to protect the client. 4) Encourage the client to tell the nurse more about what is being felt.

3 nurse must let the client know this information will be shared with the staff so the client's safety can be preserved 1, 2, 4: does not answer client's immediate concern or give client accurate information about what the nurse will do

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication? 1) Impairment of cerebral blood flow and headaches 2) Increased intracranial pressure 3) Pressure on the ocular suture line 4) Displacement of the lens implant

3 sudden changes in position, constipation, vomiting, stooping, or bending over increases the intraocular pressure and put pressure on the suture line 1 and 2: not relevant to the situation 4: occurs because of pressure on suture area; not all clients have lens implants (3 is more comprehensive answer)

Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis? 1) Flatulence 2) Nausea and vomiting 3) Right upper abdominal pain 4) Dyspepsia

3 will experience pain in the upper right abdominal quadrant 1, 2, 4: indicates other GI problem

The home care nurse plans activities for the day. In which order does the nurse see the clients? 1) The client who is breastfeeding a 2-day-old infant born 5 days before the due date 2) The client discharged yesterday after IV heparin therapy for a deep vein thrombosis 3) The elderly client who used all the diuretic medication and is expectorating pink-tinged mucus 4) The elderly client diagnosed with pneumonia and discharged from the hospital 3 days ago

3, 2, 4, 1 first- client with pink tinged mucus- symptoms of pulmonary edema; requires immediate attention second- client on heparin; still potential for problems r/t heparin; assessor bleeding gums and hematuria third- potential for relapse; assess breath sounds, encourage fluids, cough and deep breathe fourth- stable client, least critical/priority

The adult client is preparing for a plasma cholesterol screening. Which instruction dos the nurse give to the client? 1) Eat a vegetarian diet for 1 week before the test 2) Limit alcohol intake to two glasses of wine the day before the test 3) Abstain from dairy products for 48 hours before the test 4) Only take sips of water for 12 hours before the test

4 only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results 1: client should eat a normal diet the week before the test 2: alcohol intake will interfere with test results 3: normal diet should be eaten this week before the test

The client is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptom? 1) Heart palpitations 2) Dizziness when walking 3) Blurred vision 4) Digital sensitivity to cold

4 vasculitis of blood vessels in upper and lower extremities 1: no cardiac involvement 2: dizziness not seen; intermittent claudication (pain with exercise) seen 3: optic nerve not affected

The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages? 1) The umbilical cord of the 5-day-old is soft and draining exudate. 2) The circumcision site of the 3-day-old is slightly swollen. 3) When bed is bumped, a 2-day-old rapidly extends the extremities. 4) The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep.

4, 2, 1, 3 First: bulging fontanelle may indicate increased ICP and is most serious Second: circumcision should have yellowish exudate at this time, but swelling is not normal and may interfere with urination Third: umbilical cord should be dry and hard, draining indicates possible infection and needs to be assessed Last: describes the Moro reflex and is normal

The nurse cares for the homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which observation by the nurse confirms this suspicion? 1) The nurse notes that the bladder is distended 2) The client reports a constant urge to void 3) The nurse notes that the urine is concentrated 4) The client reports a burning sensation

1 bladder distention is one of the earliest signs of obstructed drainage tubing 2 and 4: seen with a UTI 3: seen with dehydration

The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is most important for the nurse to have which item available? 1) Tracheostomy set. 2) Cardiac monitor. 3) IV monitor. 4) Heating pad.

1 tracheostomy set is the most important for the client's safety due to risk for laryngospasm 2 and 3: nice to have, but not the most important 4: unnecessary

The nurse observes the student nurse auscultate the right middle lobe (RML) lung of the client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? 1) Posterior and anterior base of right side 2) Right anterior chest between the fourth and sixth intercostal spaces 3) Left of the sternum, midclavicular, at right fifth intercostal space 4) Posterior chest wall, midaxillary, right side

2 RML is found in the right anterior chest between the 4-6 intercostal spaces 1 and 4: cannot auscultate the RML from the posterior 3: point of maximum impulse of apical pulseThe

The health care provider inserts a temporary pacemaker in a client following a myocardial infection. The nurse knows that which outcome is the primary purpose of the pacemaker? 1) Increases the force of myocardial contraction 2) Increased the cardiac output 3) Prevents premature ventricular contractions (PVCs) 4) Prevents systemic overload

2 acts to regulate cardiac rhythm 1: action of cardiac glucosides such as digoxin 3: action of antiarrhythmics such quinidine 4: action of diuretics such as furosemide

The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the pattern of urinary elimination occurs normally with aging? 1) Decreased frequency 2) Nocturia 3) Incontinence 4) Hematuria

2 decreased ability to concentrate urine increases urine formation and increased nocturnal urine production leads to need to awaken to void 1: frequency increases because bladder capacity decreases 3: ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence 4: blood in urine may be a sign of cancer, infection, or trauma of urinary tract, glomerular disease, urinary tract calculi, bleeding disorders

The client is scheduled for electromyography (EMG). Which information does the nurse tell the client about the procedure? 1) "Your hair will be carefully washed prior to the procedure." 2) "This is a noninvasive procedure that takes about 30 minutes." 3) "A sedative will be given to you shortly before the procedure." 4) "You will not be allowed to eat 4 to 6 hours before the procedure."

2 electrodes are attached to muscles, length of time for impulse transmission is measured 1: performed on selected muscles, usually of the extremities 3: may impair test results 4: procedure does not involve general anesthesia or GI system

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for the 5-year-old child? 1) The child plays with a large truck with another child. 2) The child talks on a toy telephone and imitates same-sex parent. 3) The child works on a puzzle with several other children. 4) The child holds and cuddles a large stuffed animal.

2 imitative behavior seen at this age 1: cooperative play occurs in school-aged children 3: too advanced for this age 4: too regressed for this age

The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take first? 1) Decreases the IV rate to 20 mL/h and notifies the health care provider. 2) Decreases the IV rate to 100 mL/h and continues to monitor the client. 3) Discontinues the IV and starts oxygen at 6 L/min. 4) Assesses for infiltration of the IV solution.

1 20 mL/h (KVO- keep vein open) will keep access open 2: need to notify HCP; rate still too much since client is in fluid overload 3: IV line may be necessary; diuretics may be ordered 4: description indicates circulatory overload, not infiltration

The nurse assists a nursing assistive personnel (NAP) in providing a bed bath to the comatose client with incontinence. The nurse intervenes if which action is noted? 1) The NAP answers the phone while wearing gloves. 2) The NAP log rolls the client to provide back care. 3) The NAP places an incontinence pad under the client. 4) The NAP positions the client on the left side, head elevated.

1 contaminated gloves should be removed before answering the phone 2: correct way to roll a client to maintain proper alignment 3: appropriate to use incontinence pad for this client 4: appropriate position to prevent aspiration and protect the airway

The 8-year-old has been receiving chemotherapy for 6 months. The child asks, "Am I going to die?" Which response by the nurse is best? 1) "Are you afraid of dying?" 2) "Why do you ask that question?" 3) "Only God knows that answer." 4) "We won't leave you alone."

1 encourages ventilation of thoughts and feelings regarding the concern 2: inappropriate 3 and 4:ignores the child's concern with dying

Which is the most appropriate nursing action to take before administering captopril? 1) Check the client's apical pulse 2) Check the client's blood pressure. 3) Check the client's urine output. 4) Check the client's temperature.

2 captopril is an antihypertensive that necessitates assessment of BP before administration 1 and 3: important, but not a priority 4: unnecessary to assess prior to the administration of the medication

The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings? 1) A pincer grasp 2) Sitting with support 3) Tripling of the birth weight 4) Presence of the posterior fontanelle 5) Playing peek-a-boo 6) Rolling from back to abdomen

2, 5, 6 1: present at 9 months 3: 1 year 4: posterior fontanelle closes at 2-3 months of age

The client has been taking propranolol 40 mg bid and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg tid to the client's medication regimen. It is most important for the nurse to assess the client for which symptom? 1) Tachycardia. 2) Diarrhea. 3) Peripheral edema. 4) Impotence.

3 verapamil is a calcium channel blocker, depress myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure 1: will cause bradycardia 2: usually causes constipation 4: not most important or frequent adverse effects

The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use? 1) Benzodiazepines 2) Marijuana 3) Barbiturates 4) Narcotics

4 narcotics are most often used intravenously 1, 2, 3: not commonly used intravenously

The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms? 1) Kussmaul respirations and bradycardia 2) Elevated temperature and slow respiratory rate 3) Expiratory wheezing and substernal retractions 4) Inspiratory stridor and restlessness

4 this condition is characterized by edema and inflammation of upper airways 1: Kussmaul respirations are associated with DKA; hypoxia and anxiety are associated with tachycardia 2: RR would be increased 3: more often noted with respiratory distress of the newborn

The nurse knows that according to Erikson's stages of psychosocial development, which development stage best represent a 50-year-old client? 1) Integrity vs despair and disgust 2) Generativity vs stagnation 3) Intimacy vs isolation 4) Identity vs role diffusion

2 stage of development is appropriate for 45- 64 years o age 1: appropriate for ages 65+ 3: appropriate for young adult 4: appropriate for the adolescent

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? 1) Paranoia 2) Grandiose delusions 3) Somatic difficulties 4) Difficulty concentrating 5) Agitation 6) Distorted perceptions

2, 4, 5 1: related to schizophrenia 2: delusions of grandeur are common during mania 3: related to personality disorders 4: due to excessive activities 5: clients are constantly in motion 6: related to depression

The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms? 1) Stomatitis and photosensitivity 2) Bradycardia and dry mouth 3) Fluid retention and dizziness 4) Gynecomastia and impotence

3 NSAID used as analgesic; adverse effects include headache, dizziness, GI distress, pruritus, rash, nausea, nephrotoxicity 1, 2, 4: not adverse effects seen with this medication

The client has a history of hypertension and angle-closure glaucoma. Which medication order does the nurse question? 1) Propranolol 80 mg PO QID 2) Verapamil 40 mg PO TID 3) Tetrahydrozoline 2 drops in each eye TID 4) Timolol 1 drop in each eye once daily

3 contraindicated with angle-closure glaucoma; ophthalmic vasoconstrictor; use cautiously with HTN 1: antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma 2: calcium channel blocker used as antianginal, not contraindicated 4: reduces aqueous formation and increases outflow, used for glaucoma

The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication? 1) The client's electrolytes 2) The client's urine output 3) The client's weight 4) The client's heart rate

4 verapamil is indicted for the treatment of supraventricular tachycardia, so the client's heart rate should be checked prior to administer 1, 2, 3: unnecessary action

The health care provider prescribes estrogen 0.625 mg daily for the 43-year-old woman. The nurse identifies which symptom as a common initial adverse effect of this medication? 1) Nausea 2) Visual disturbances 3) Tinnitus 4) Ataxia

1 common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence 2 and 3: seen with long-term use 4: unsteady gait rarely seen

The client develops a low intestinal obstruction. The nurse anticipates which findings? 1) Nausea 2) Vomiting 3) Explosive diarrhea 4) Tarry stool 5) Abdominal distention 6) Rectal bleeding

1, 2, 5 1 and 2: nothing moving in the intestine causes nausea and vomiting 3 and 4: blockage causes no stool 5: as stool backs up, distention occurs 6: blockage results in no stool and no bleeding is associated

A newborn client at 32 weeks' gestation weighs 4 lb 10 oz (2.12 kg) and has mottling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect this client is experiencing? 1) Hypoglycemia. 2) Cold stress. 3) Birth asphyxia. 4) Hypovolemia.

2 Mottling of the skin, acrocyanosis, and irregular respirations at the rate of 60 breaths per minute are symptoms of cold stress. 1: Newborn hypoglycemia is a blood glucose level less than 25 mg/dL (1.4 mmol/L). Symptoms include cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, and coma. 3: Meconium-stained amniotic fluid is associated with birth asphyxia. 4: Symptoms of shock occur in hypovolemia.

The nurse assesses the client with severe bilateral peripheral edema. Which is the best way for the nurse to determine the degree of edema in a limb? 1) Measure both limbs with the tape measure and compare. 2) Depress the skin and rank the degree of pitting. 3) Describe the swelling in the affected area. 4) Pinch the skin and note how quickly it returns to normal.

2 severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) 1: is not the best way to evaluate for peripheral edema 3: not as objective 4: is used for evaluating hydration

The nurse obtains a specimen from the client for sputum culture and sensitivity. Which instruction is best? 1) After pursed lip breathing, cough into a container 2) Upon awakening, cough deeply and expectorate into a container 3) Save all sputum for three days in a covered container 4) After respiratory treatment, expectorate into a container

2 specimens should be obtained in the early morning because secretions develop during the night 1: coughing into a container is indicated, but not pursed-lip breathing 3: appropriate for acid-fast stain for TB 4: earliest specimen is most desirable

The nurse assesses a client diagnosed with a spinal cord injury. Which finding suggests the complication of autonomic dysreflexia? 1) Urinary bladder spasm pain 2) Severe pounding headache 3) Profuse sweating 4) Dysrhythmias 5) Severe hypotension 6) Nasal congestion

2, 3, and 6 1: an overfilled bladder may be the cause, but pain is not perceived 2: results from rapid onset of hypertension and is one of the classic symptoms 3: esp. on forehead, another classic symptom of dysreflexia 4: bradycardia is the most common change in pulse; not a symptom of dysreflexia 5: the blood pressure will increase and may rise to a very high level 6: Nasal congestion occurs with dysreflexia and piloerection (goose flesh) may also occur

The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expect the client to present? 1) View appearance as "skinny." 2) Be hypoactive and withdrawn. 3) Want to discuss and plan meals. 4) Have a close relationship with a parent.

3 display a marked preoccupation with food 1: usually view the appearance as fat 2: inaccurate for client with anorexia nervosa 4: inaccurate for client with anorexia nervosa

The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8, and the client is non responsive. Naloxone hydrochloride 0.4 mg IV is ordered stat. It is important for the nurse to consider which action? 1) The BP and respirations will need to increase before a second dose of naloxone can be given 2) Naloxone should not be given to the client because of the DNR status 3) A dose of naloxone may need to be repeated in 2-3 minutes 4) Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives

3 half-life of naloxone is short; may go back into respiratory depression; may need to be repeated 1: will not change without naloxone, respirations increase within 2 min 2: DNR indicates no resuscitation if heart stops; does not preclude administration of medications to correct iatrogenic problems 4: used for respiratory depression of opiates, not used with sedatives or barbiturates

The nurse obtains the client's temperature of 103° F (39.4° C). The nurse knows body compensatory mechanisms include which mechanism? 1) Decreased respiratory rate and bradycardia. 2) Normal blood pressure and pulse. 3) Increased respiratory rate and tachycardia. 4) Diaphoresis with cool, clammy skin.

3 hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate 1: respirations and health rate with increase with fever 2: blood pressure and pulse usually increase with fever 4: diaphoresis may occur, but the skin will be warm

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure? 1) Inserts the suction catheter 4 in into the tube. Applies suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2) Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions while removing the catheter in a back and forth motion. 3) Explains the procedure to the client. Inserts the catheter gently while applying suction, and withdraws using a twisting motion. 4) Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.

4- Inserts suction catheter until resistance met without applying suction, withdraw 1-2 cm and apply intermittent suction with twirling motion 1: inserted until resistance met, never suction longer than 10-15 seconds 2: twirling motion when removing catheter 3: suction never applied when catheter is inserted

The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? 1) Protruding soft abdomen with frequent diarrhea 2) Distended abdomen with ascites 3) Minimal bowel sounds in all four quadrants 4) Distended abdomen with reports of pain

4 if an obstruction is present, the abdomen will become distended and painful 1 and 2: does not support intestinal obstruction 3: immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen

The client reports a severe headache, nausea, and photophobia. The health care provider orders a CBC and LP. A diagnosis of bacterial meningitis is made. Which laboratory result does the nurse expect? 1) CSF cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm^3 2) CSF with red blood cells, Hgb 10 g/dL, HCT 37%, WBC 8,000/mm^3 3) CSF cloudy, Hgb 12 g/dL, HCT 37%, WBC 7,000/mm^3 4) CSF clear, Hgb 15 g/dL, HCT 40%, WBC 11,000 mm^3

1 CSF normally clear and colorless, normal WBC 5,000-10,000 mm^3, normal Hgb male 13-18 female 12-16 g/dL; normal HCT male 42-52% female 35-47%; cloudy CSF indicates inflammation/infection, Hgb and HCT are within normal ranges, WBC is elevated indicating infection 2: indicates trauma or hemorrhage 3: WBC too low, not typical of bacterial meningitis 4: indicates viral meningitis; clear CSF, increase in WBC not as significant as bacterial meningitis

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? 1) The bowel preparation is incomplete 2) The client ate something after midnight 3) This is an expected finding before this type of surgery 4) The client passed the last stool left in the colon

1 Colon should not have remaining soft stool 2: anything eaten after midnight would not appear as stool by the next morning 3: not expected, need to clean GI tract for surgery 4: assumption, not substantiated

The parent tells the nurse about having had difficulty forming relationships. The parent is worried the 7-year-old child will have the same problem. Which statement by the nurse is best? 1) Children develop trust from birth to 18 month of age 2) Children develop trust from 18 months to three years of age 3) Children develop trust from 3-6 years of age 4) Children develop trust from 6-12 years of age

1 Eriksson states that trust results from interaction with dependable, predictable primary caretaker 2: toddler stage concert autonomy versus shame and doubt 3: preschool stage concert initiative versus guilt 4: latency or school age stage concerns industry versus inferiority

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1) Projection and displacement 2)Sublimation and internalization 3) Rationalization and intellectualization 4) Reaction formation and symbolization

1 Projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object) 2: Sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else's opinion as one's own) 3: Rationalization (attempt to make behavior appear to be the result of logical thinking) and intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings) 4: Reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and symbolization (something represents something else); symbolization is involved in phobias

The nurse enters a client's room wearing a gown in addition to gloves. Which is the client diagnosis based on the chosen personal protective equipment? 1) Respiratory syncytial virus 2) Kawasaki disease 3) Lyme disease 4) Infectious mononucleosis

1 RSV is an acute viral infection. According to the CDC, this infection requires contact precautions in addition to standard precautions. The client may be assigned to a private room or with other RSV- infected clients 2: acute systemic vasculitis occurring in children under the age of five years; standard precautions required when giving care 3: connective tissue disease spread by tick bites; standard precautions required 4: viral disease spread through saliva; standard precautions required

The outpatient clinic nurse cares for an elderly client diagnosed with Type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1) The renal threshold for glucose is elevated in the elderly 2) Blood glucose monitoring is easier and less costly for clients to perform 3) Urine testing for glucose provides false-positive readings 4) Determination of the color on a reagent strip varies from person to person

1 The level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels 2: more expensive procedure 3: provides false-negative readings 4: results are expressed as a percentage according to color change

The client is treated in the telemetry unit for cardiac disease. The client receives propranolol hydrochloride 20 mg PO at 09:00. When the nurse enters the room to give the medication to the client, the nurse finds the client wheezing with a nonproductive cough and shortness of breath. Initially the nurse takes which action? 1) Holds the medication and counts the respirations. 2) Holds the medication and calls the health care provider. 3) Takes an apical pulse and then gives the medication. 4) Gives the mediation as ordered.

1 adverse effects include increased airway resistance; client is experiencing bronchospasm; should assess and then call the health care provider 2: should assess the client's condition first 3: client is experiencing an adverse effect; medication should not be given 4: medication should be held; client is experiencing an adverse effect

The older client is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which instruction about moving does the nurse give to encourage the client to participate in care? 1) "Pull up on the overhead trapeze while you push down on your right foot to lift your body." 2) "With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently." 3) "I'll raise the head of the bed 45 degrees, and then you'll lean forward and rotate your hips to the left." 4) "Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."

1 body must move as single, straight unit 2: turning or twisting from the waist down interferes with countertraction 3: prevents proper pull of weights 4: can't turn from side to side; can only move up and down

The 7-year-old child is having some difficulty adjusting to the parents' impending divorce. The HCP suggests play therapy. The nurse identifies which reason this is effective for this age group? 1) Young children have difficulty verbalizing emotions 2) Children hesitate to confide in anyone but their patients 3) Play is an enjoyable form of therapy for children 4) Play therapy is helpful in preventing regression

1 children have difficulty putting feelings into words; play is how they express themselves 2: somewhat true, but not best reason for play therapy 3: not reason play therapy is used; is used because it is the best way for children to express themselves 4: may encourage child to act out earlier developmental stage to reveal underlying conflicts

The parent brings 10-year-old and 3-year-old children to the pediatric office. The younger child reports dysuria. The health care provider orders a catheterized urine specimen. The nurse takes which action? 1) Describes the procedure to the child in short, concrete terms while talking calmly. 2) Allows the child to play with the equipment during the procedure. 3) Involves the older sibling in explaining the procedure. 4) Shows the child a diagram of the urinary system.

1 children this age needed simple explanations 2: might contaminate the equipment; must be a sterile procedure 3: not likely to listen to sibling 4: not appropriate for this age

The nurse plans care for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1) Cause the client to defend the idea 2) Help the client clarify thoughts 3) Facilitate better communication 4) Lead to a breakdown of the defense

1 contraindicated; encourages client to engage in further distortion of reality 2: needs reality testing from nurse, not questioning 3: questioning is nontherapeutic; may cause client to avoid nurse physically 4: needs defense; questioning will further distort reality or elaborate on delusion

The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom? 1) Delusions of persecution 2) Command hallucinations 3) Delusions of reference 4) Persecution hallucinations

1 delusion is a strongly held belief that is not validated by reality; the idea that a family ember is trying to steal property is a belief not validated by reality 2: hallucinations are sensory perceptions that take place without external stimuli; most common are auditory (hearing voices); other types of hallucinations are tactile, visual. gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something (i.e. to kill someone) 3: delusions of reference are a false belief that public events or people are directly related to the individual 4: are not hallucinations

The client is admitted to the hospital for a hemiglossectomy with lymph node dissection. The client's preoperative care includes frequent oral hygiene with normal saline. The nurse knows the purpose of this treatment includes which reason? 1) Minimizes the bacterial count in the mouth. 2) Softens the mucous membranes of the tongue before surgery. 3) Stimulates the microcirculation of the mouth. 4) Hydrates the tissues of the gums.

1 destroys bacteria found in mouth, reduces the chance of infection 2: is not the action of saline 3: circulation is unaffected by a mouth rinse 4: has slight drying effect on mucous membranes

The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate? 1) "You are less likely to awaken during the night with heartburn if the stomach is empty." 2) "Early-morning vomiting will be less of a problem if the stomach is empty." 3) "Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs." 4) "You may develop fluid overload if fluids are taken just before going to bed."

1 full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn 2: vomiting is not related to hiatal hernia 3: decreased respirations not r/t hiatal hernia 4: fluid overload is not r/t hiatal hernia

The nurse prepares discharge teaching for the parents of the newborn. Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test? 1) The initial specimen should be collected as close to discharge as possible but not later than 7 days 2) The infant can have water but should not have formula for 6 hours before the test 3) The test will need to be repeated at 6 weeks and at the 3-month check-up 4) Blood will be drawn at three 1-hour intervals; there is no specific preparation

1 if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age 2: no restrictions on formula intake 3: test may be repeated within 2 weeks to ensure accuracy 4: only one blood sample is needed

The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1) Rice cereal is usually the first solid food and is started around 4-5 months 2) Strained fruits are well tolerated as the first solid food, and infants like them 3) Introduction of solid foods is not important at this time 4) Solid foods are usually not started until the infant is around 6 months old.

1 infants are less likely to be allergic to rice cereal than to any other solid food; breast-fed infants may be started on solids even later 2: inaccurate 3: does not answer parent's question 4: usu. started between 4-5 months

The charge nurse makes client assignments on the maternity unit. The RN has been reassigned to the maternity unit from outpatient surgery. Which client does the charge nurse assign to the RN? 1) The client at 16 weeks gestation admitted with hyperemesis and receiving IV fluids. 2) The client at 26 weeks gestation in premature labor and receiving terbutaline. 3) The client at 32 weeks gestation with a placenta previa and ruptured membranes. 4) The client at 37 weeks gestation with severe preeclampsia and epigastric pain.

1 monitor IV therapy, administer antiemetics and nutritional supplements 2: monitor client's response to medication and the status of the fetus 3: prepare for delivery, closely monitor fetal response 4: indicates impending seizures, prepare for delivery

The 25-year-old primigravida is diagnosed with type 1 diabetes mellitus. The nurse reviews the insulin regimen with the client. The nurse explains insulin needs will change in which way? 1) Increase during pregnancy and decrease after delivery. 2) Decrease during pregnancy and increase after delivery. 3) Increase during pregnancy and remain increased after delivery. 4) Decrease during pregnancy and fluctuate after delivery.

1 needs increase during pregnancy due to hormonal interference in glucose metabolism 2: needs increase during pregnancy due to hormonal interference in glucose metabolism 3: insulin needs will decrease after delivery 4: insulin needs increase during pregnancy

The nurse observes the fetal heart monitor pattern below for the client in active labor. Which pattern does the nurse identify for this monitor strip? (IMAGE) 1) Early Deceleration. 2) Late Deceleration. 3) Variable Deceleration. 4)Decreased Variability.

1 occurs in response to compression of fetal head; uniform shape corresponds to contracts, does not indicate fetal distress 2: late decelerations show decreasing fetal heart rates that correspond to the increasing uterine contraction; abnormal finding indicating utero-placental dysfunction 3: variable decelerations are rapid in decent and commonly do not correspond to the uterine contraction pattern; found with cord compression. 4: decreased variability is noted as a flattening of the fetal baseline; not noted on this strip

The nurse cares for the client one day after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe q 2 h. Which does the nurse understand to be the purpose of this nursing action? 1) Promote ventilation and prevent respiratory acidosis. 2) Increase oxygenation and removal of secretions. 3) Increase pH and facilitate balance of bicarbonate. 4) Prevent respiratory alkalosis by increasing oxygenation.

1 primary purpose of this nursing measure is to improve and.or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis 2: promoting ventilation and preventing respiratory acidosis better because it refers to ventilation rather than oxygenation 3: increasing the pH is not desirable 4: respiratory alkalosis is not prevented by this nursing measure

The nurse responds to a train derailment. After making initial assessments, in what order should the nurse see these clients? 1) The young client with blood pulsating from a cut on the right leg. 2) The unconscious client with the right leg shorter than the left leg. 3) The pregnant client who states clothing is wet. 4) The preschool child who is screaming and crying uncontrollably.

1, 2, 3, 4 1: indicates arterial bleeding; apply direct pressure; high risk for shock. 2: possible hip fracture; no indication of respiratory difficulty stated; client unconscious, may have other problems. 3: requires further assessment; could be amniotic fluid or could be urine. 4: stable client; no indications of any injuries.

The nurse administers Rho(D) immune globulin to prevent complications in which client situation? 1) The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. 2) The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 3) The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. 4) The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

2 Rho(D) immune globulin is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test 1: if both mother and baby are Rh-negative, there is no problem 3: mediation is not given if the mother has been sensitized by a previous pregnancy 4: there is no incompatibility here because Rh-positive mothers are not at risk for Rh incompatibility; only Rh-negative mother with Rh-positive fetus

A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the client to make which statement about symptoms? 1) "I have been having difficulty with my hearing." 2) "I lose my balance easily." 3) I can't tell the difference between a sweet and sour taste." 4) "It is not easy for me to remember names and faces."

2 cerebellum maintains balance 1: temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic 3: CN IX, glossopharyngeal responsible for differentiation of taste 4: not specific symptom of cerebellum dysfunction

Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1) "I love my family with all my heart, even though they don't love me." 2) "I was unable to take my final exams because I was unable to write." 3) "I don't believe I have diabetes. I feel perfectly fine." 4) "If my spouse was a better housekeeper I wouldn't have such a problem."

2 client has converted the anxiety over school performance into a physical symptom that interferes with the ability to perform 1: indicates reaction formation 3: indicates denial 4: indicates projection

The elderly alcoholic client receives a long-acting benzodiazepine for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which problem? 1) A reaction to the sedative medication. 2) A worsening course of the withdrawal syndrome. 3) An exacerbation of the schizophrenia process. 4) The process of aging and the effects of delirium.

2 client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations 1: client has been medicated with benzodiazepines and did not experience untoward reactions 3: schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations 4: combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementia

The nurse performs the Rinse test on a client. Which is an accurate statement of how the first part of this test is performed? 1) The stem of a vibrating tuning fork... is held against the auditory canal until the client indicates sound can no longer be heard. 2) held against the mastoid bone until the client indicates sound can no longer be heard 3)held in the middle of the forehead and th clients hearing is assessed in both ears 4) positioned 2 inches behind the client's head, and the length of time sound heard is documented

2 client should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction 1 and 4: inaccurate 3: the Weber test

The client asks what the difference is between a gastric ulcer and a duodenal ulcer. Which response does the nurse give? 1: "Gastric ulcers have an increased association with clients who experience greater psychological pressures." 2: "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 3: Clients with gastric ulcers often gain weight, as food alleviates the pain." 4: "Antacids are seldom prescribed for clients with duodenal ulcers.

2 clients with duodenal ulcers experience pain after meals (e.g., midmorning and midafternoon) 1: refers to duodenal ulcers 3: clients with gastric ulcers may be malnourished because food may cause nausea or vomiting 4: antacids are given to duodenal ulcer clients

The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred to assertiveness skills classes. This is an appropriate intervention because the client may exhibit which problem? 1) Aggressive behaviors and angry feelings 2) Self-identity and self-esteem issues 3) An intense focus on reality 4) Family boundary intrusions

2 clients with eating disorders experience difficulty with self-identity and esteem, which inhibits their abilities to act assertively; some techniques taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do 1: these clients do have problems with feelings of anger; family therapy sessions can be helpful identifying some of these feelings and difficulties with family boundaries 3: do not have problems with reality 4: these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

The client with newly diagnosed type 1 diabetes says to the nurse, "I know I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which response by the nurse is best? 1) "It is best to buy new shoes in the morning." 2) "Have each foot measured every time you buy new shoes." 3) "Buy shoes a half-size larger than your foot size so the fit is roomy." 4) "Buy vinyl shoes because they won't lose their shape easily."

2 feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger) 1: should buy shoes in the afternoon when feet are larger in the morning 3: buy correct shoe size 4: leather shoes recommended because they "breathe", vinyl could cause foot to perspire and aggravate fungal infections

The nurse teaches a health class to a group of senior citizens. Which behavior does the nurse emphasize to facilitate regular bowel elimination? 1) Avoid strenuous activity. 2) Eat more foods with increased bulk. 3) Decrease fluid intake to decrease urinary losses. 4) Use oral laxatives so a bowel pattern emerges.

2 fiber contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis 1: regular exercise program facilitates bowel elimination 3: normal fluid intake of 1,500 mL/day facilitates bowel elimination 4: laxatives used as last resort because they become habit-forming

The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made? 1) There is no drainage in the collection chamber for 3 hours 2) The fluid in the water-seal chamber does not fluctuate with respirations 3) There is continuous bubbling in the water-seal chamber 4) There is gently bubbling in the suction-control chamber

2 indicates no more air leaking into pleural space 1: doesn't indicate re-expansion 2: indicates air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling 4: normal finding

The HCP orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication? 1) The blood pressure increases to 150/90 2) Urinary output increases to 175 mL/hour 3) There is a decreased in the level of activity 4) There is an absence of fine tremors of the fingers

2 mannitol is an osmotic diuretic; increases urinary output and decreases ICP 1: Increase in blood pressure is not desired 3 and 4: does not indicate desired effect of medication

The client is admitted to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. The client receives morphine sulfate. Which finding does the nurse recognize as the desired response to the medication? 1) Increase in pulse pressure 2) Decrease in anxiety 3) Depression of the sympathetic nervous system 4) Enhanced ventilation and decreased cyanosis

2 morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema 1: is not affected by morphine sulfate 3: is not the action of the medication 4: medication does not improve ventilation

The client has a three-way indwelling urinary catheter following a transurethral resection. Which finding causes the nurse to infuse the irrigating solution rapidly? 1) The urinary output is increased. 2) Bright-red drainage or clots are present. 3) Dark-brown drainage is present. 4) The client reports pain.

2 nurse should irrigate three-way urinary catheter rapidly when bright-red drainage or clots are present; nurse should decrease irrigation rate to about 40 gtt/min when the drainage clears 1, 3, 4: not an indication to infuse irrigating solution rapidly

The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurse's liability? 1) The nurse administered the medication appropriately; there is no liability 2) There is no order for a second dose of medication; the nurse is liable 3) The client was not injured; if injury did not occur, then the nurse is not liable 4) The nurse should have waited at least 4 hours; then there would be no liability

2 order for a stat dose is for a one time administration; nurse practice act address scope of practice; by administering a second dose the nurse was prescribing the medication, something only a HCP with prescriptive ability can do 1: does not address he fact that there was no order for the morphine to be repeated 3: negligence addresses harm, not liability 4: there was no time range written in the order; illegal to administer a second dose

The nurse cares for the prenatal client at 8 weeks gestation with a positive VRDL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information? 1) Advise the client not to take any OTC mediations 2) Instruct the client about the importance of taking all of the medication 3) Inform the client to refrain from sexual activity 4) Maintain the confidentiality of sexual partners or contact

2 physical, vitally important to complete all the medication Think Maslow 1: physical but not highest priority 3: physical, more important to be treated for disease 4: psychosocial, communicable diseases are reportable

The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process? 1) Elderly adults eat a small volume of food with decreased bulk 2) EA engage in less activity and have decreased GI muscle tone 3) Elderly adults have neurological changes in the GI tract 4) EA have decreased sensation in the GI tract

2 reduced GI motility due to decreased muscle tone and exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, adverse effect of meds, emotional problems, insufficient fluid intake, and excessive dietary fat 1: Decreased intake of high-fiber foods due to chewing difficulties is seen but is not a major cause of constipation 3 and 4: decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation

The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? 1) Maintain and improve the quality of oxygenation 2) Improve the status of ventilation 3) Increase oxygenation of peripheral circulation 4) Correct the bicarbonate deficit

2 refers to levels of carbon dioxide and oxygen 1: primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state 3 and 4: not appropriate for the situation

The young adult is immobilized for trauma to the spinal cord. The client has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which is the most important nursing diagnosis? 1) Risk for Constipation related to immobilization. 2) Risk for Impaired Skin Integrity related to immobilization and secretions. 3) Risk for Infection related to involuntary bowel secretions. 4) Risk for Fluid Volume Excess related to secretions.

2 skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this 1: constipation is not a problem because the client has diarrhea 3: not most important 4: may be at risk of deficient fluid volume due to diarrhea and secretions

The 11-year-old child falls off a bicycle and sustains a minor head injury. The injury is treated at the outpatient clinic. The nurse instructs the child's parent about care at home. The nurse determines further teaching is needed if the parent makes which statement? 1) "My child may have dizziness for 24 hours." 2) "My child can drink carbonated beverages if vomiting occurs." 3) "My child may report feeling nauseated." 4) "My child will probably have a headache."

2 vomiting is unexpected; should be reported to health care provider immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache 1 and 3: expected for at least 24 hours 4: expected for at least 24 hours; should not get more intense

The client is admitted for regulation of insulin dosage. The client takes 15 units of isophane insulin at 08:00 every day. At 16:00, which nursing observations indicate a complication from the insulin? Select all that apply. 1) Acetone odor to the breath. 2) Irritability. 3) Polyuria. 4) Tachycardia. 5) Headache. 6) Diaphoresis.

2, 4, 6 isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur. 1, 3, 5: related to hyperglycemia

The client is to have an intravenous pyelogram (IVP). Nursing management includes which action? 1) A fat-free meal the evening before the examination and radiopaque tablets at bedtime. 2) Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter. 3) Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4) Explaining the importance of following directions regarding voiding during the test.

3 because of need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered 1: fat-free meal is associated with a gallbladder series 2: a retention indwelling catheter may be in place, but not for the purpose of dilating the bladder sphincter 4: there are few directions the client needs to follow during the test

The client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows which behavior best describes the client's need for repetitive acts of hand-washing? 1) Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2) Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body. 3) Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. 4) Hand-washing helps maintain the client in an active state to resist the effects of depression.

3 compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing 1: not a manipulation on the client's part 2: not an accurate statement regarding the compulsive behavior of this client 4: client is not subject to depression but to high levels of anxiety

The nurse cares for the client the first day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asked why the client has the CBI. Which response by the nurse is best? 1) The CBI prevents urinary stasis and infection 2) The CBI dilutes the urine to prevent infection 3) The CBI enables urine to keep flowing 4) The CBI delivers medication to the bladder

3 CBI prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client 1: refers to a possible preoperative complication of infection due to the enlarged prostate 2: not the reason for the CBI 4: medication is not routinely administered via a CBI in a first-dat postoperative TURP

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1) "The father transmits the gene to the son." 2) "Both the mother and father carry a recessive trait." 3) "The mother transmits the gene to her son." 4) "There is a 50% chance that the mother will pass the trait to each of the daughters."

3 Hemophilia is a sex-linked disorder 1: affected male inherits gene from the mother and can transmit it only to the daughters 2: not AR trait 4: there is a 50% chance the mother will pass the trait to each of her children

The nurse in the pediatric office observes the child in the waiting room. The child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1) 1 year old. 2) 2 years old. 3) 3 years old. 4) 5 years old.

3 able to jump with both feet and stand on one foot momentarily at 30 months 1: unable to walk up and down stairs with hand held until 18 months 2: unable to jump until 30 months 4: behaviors are seen in younger child

The nurse knows that cortisol is responsible for which action? 1) Preparing the body for "flight or fight" 2) Regulating the calcium metabolism 3) Converting protein and fat into glucose 4) Enhancing musculoskeletal activity

3 action of cortisol, is also an anti-inflammatory agent 1: action of epinephrine 2: actions of parathyroid hormone 4: action of norepinephrine

The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring? 1) An adverse effect of the medication that will disappear as time passes 2) The reason the client is receiving this medication 3) Extrapyramidal adverse effects resulting from this medication 4) An indication the dosage of the medication needs to be increased

3 adverse effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing) 1: untrue statement; dosage may need to be decreased because of adverse effect of medication; antiparkinson medication such as benztropine may be ordered 2: not accurate- antipsychotic med 4: dosage may be decreased; antiparkinsonian medication such as benztropine may be ordered

The nurse supervises care given to clients on a medical surgical unit. The nurse intervenes if which activity is observed? 1) The nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition. 2) The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition. 3) The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen. 4) The nurse wears a disposable particulate respirator when administering rifampin to the client with tuberculosis.

3 applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodbourne pathogens may occur 1: appropriate procedure, prevents airborne contamination 2: insulin is the only medication that can be given, compatible with TPN 4: use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour

The nurse develops care plans for these four clients. The nurse plans to use a restraint for which client? 1) The infant with septicemia 2) The child after a tonsillectomy 3) The infant after a cleft lip repair 4) The child with meningitis

3 arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line 1, 2, and 4: not in need of restraints

The client receives tetracycline. The nurse includes which information in the teaching plan? 1) Take the medication with milk or antacids to decrease GI problems. 2) The medication should always 3) Use a maximum-protection sunscreen when outdoors. 4) Crackers and juice will help decrease gastric irritation.

3 because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure 1: tetracycline should never be taken with milk or antacids because these inhibit the medication's action 2: should take with full glass of water at least 1 hour before or 2 hours after meals 4: should take with full glass of water at least 1 hour before or 2 hours after meals

The client has partial-thickness and full-thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed? 1) Epigastric pain. 2) Restlessness. 3) Tachypnea. 4) Lethargy.

3 body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color 1: insignificant for burn client 2 and 4: may be due to pain

The office nurse reinforces the health care provider's explanation for a myelogram. Which statement correctly describes a myelogram for the client? 1) "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2) "The test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3) "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4) "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."

3 contrast medium is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, herniated vertebral disks 1: x-ray examination cannot determine the extent of myelin breakdown 2: no such procedure; injecting contrast medium into a ruptured disk would not allow visualization of the spinal column 4: no such procedure; air is not injected into the subarachnoid space

The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor? 1) To evaluate the progress of the client's labor. 2) To assess the strength and duration of the client's contractions 3) To monitor the oxygen status of the fetus during labor 4) To determine if an oxytocin drip is necessary

3 goal is early detection of mild fetal hypoxia 1: clinical assessments provide information about progress of labor (dilation and effacement) 2: not most important reason for monitoring 4: fetal well-being is most important reason for fetal monitoring

The nurse prepares a dopamine infusion for the client. Which action does the nurse take first? 1) Evaluates the urine output 2) Obtains the client's weight 3) Determines the potency of the IV line 4) Measures pulmonary artery pressures

3 if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious adverse effects 1 and 4: not a critical assessment at this time 2: contains correct information but is not a priority

A client has a modified radical mastectomy and axillary dissection. The nurse identifies which client concern as the basis for the priority nursing diagnosis immediately after the procedure? 1) Expresses concern about hearing the pathology report results 2) An extensive surgical wound is covered with a large dressing 3) Expresses a need for medication for severe pain 4) A need for assistance to sit up and complete self-care

3 immediately after surgery, the priority is optimizing the client's comfort; if pain control is not addressed, the client may progress to difficulty with breathing 1: anxiety is psychosocial and may require intervention; however, this is not the priority concern immediately after surgery 2: the surgical wound is physical, and there is always concern about the suture line and infection; however- in the immediate period of time, this is not a priority 4: caring for self is not a priority as there is little the client needs to do in the period immediately after surgery

The nurse cares for the client with a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1) Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. 2) Handle the radium carefully using forceps and rubber latex gloves. 3) Document the date and time of removal together with the total time of implant treatment 4) Double-bag the radium implant before the person from radiology removes it from the room

3 important that accurate documentation be maintained on the internal radium implant 1, 2, and 4: at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

Which is the most important for the rehabilitation nurse to assess during a new client's admission? 1) The client's expectations of family members 2) The client's understanding of available supportive services 3) The client's personal goals for rehabilitation 4) The client's past experiences in the hospital

3 it is important for the nurse to understand what the client expects from the rehabilitation program for future success 1, 2, 4: important to assess but is not as crucial for future success as the client's goals

The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding? 1) Sensation loss in an upper extremity. 2) Clonic jerks in the affected foot. 3) Paresthesia in the affected leg. 4) Chorea in the upper and lower extremities.

3 lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities 1: results from cervical lesions 2: can occur in a person who has been paralyzed from a spinal cord injury 4: is a sign of Huntington Chora, resulting from atrophy of parts of the brain

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1) Tetralogy of Fallot 2) Talipes equinovarus 3) Hemolytic disease of the newborn 4) Cleft lip and palate

3 maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis 1: cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle 2: congenital deformity detected at birth; foot twisted out of normal position, clubfoot 4: congenital deformity detected at birth, midline fissure or opening into lip and/or palate

The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents? 1) Apply the cream rinse every other day for 1 week. 2) Wash the child's clothing and personal belongings in soap and cool water. 3) Repeat the application of the cream rinse in 7 days if nits are still present. 4) Comb the child's hair weekly with a nit comb.

3 may be repeated 7 days after first application 1: too frequent an application of the rinse 2: wash with detergent in very hot water and dry for 20 minutes in a dryer 4: hair should be combed daily with a nit comb

The health care provider orders morphine sulfate 8 mg IM q 3 to 4 h for pain PRN. In which situation does the nurse consider withholding the medication until further assessment is completed? 1) The client reports acute pain from a partial-thickness burn affecting the lower left leg. 2) The client's blood pressure is 140/90, pulse is 90, and respiration is 28. 3) The client's level of consciousness fluctuates from alert to lethargic. 4) The client exhibits restlessness, anxiety, and cold and clammy skin.

3 morphine depresses CNS, especially respiratory center in medulla 1: morphine is used for moderate to severe pain; the nurse should give the medication 2: BP slightly elevated, respirations elevated, may be the result of pain; the nurse should give the medication 4: may be the result of pain

The client is diagnosed with an obsessive-compulsive ritual. The nurse recognizes the client is attempting to achieve which psychological status? 1) Control of other people. 2) Increased self-esteem. 3) Avoid severe levels of anxiety. 4) Express and manage anxiety.

3 obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so 1 and 2: inaccurate 4: ritual is not a method of expressing anxiety but a strategy to avoid it

The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which goal as the primary goal of this type of group activity? 1) Provides psychosocial educational opportunities for stress and coping 2) Provides an avenue for physical exercise 3) Provides an environment for social interaction and companionship 4) Reorients and provides a reality test for confused clients

3 primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members 1 and 2: not primary goal of a reminiscing group 4: groups that facilitate orientation to time, person, place, and current events are called reality orientation groups

The nurse prepares the client for a magnetic resonance imaging (MRI). Which client statement indicates the teaching is successful? 1) The dye used in the test will turn my urine green for about 24 hours. 2) I will be put to sleep for this procedure. I will return to my room in two hours. 3) This procedure will take about 90 minutes to complete. There will be no discomfort. 4) The wires that will be attached to my head and chest will not cause me any pain.

3 procedure takes approx. 90 minutes and is not painful 1: if contrast is used, it does not change the color of the urine 2: client is not anesthetized for this procedure 4: indicates misunderstanding of MRI because no wires are used

The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for which client? 1) The client 1 day postoperative after an internal fixation of a fractured left femur 2) The client receiving diltiazem and phenytoin 3) The client ordered to receive two units of packed cells 4) The client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder

3 requires the assessment and teaching skills of the RN 1: care can be assigned to the nursing assistive personnel; standard, unchanging procedure 2: medication can be given by the LPN 4: offer food and fluids; assign to the LPN

The client returns from surgery. There is a fine, reddened rash around the area where providone iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? 1) Time and circumstances under which the rash was noted 2) Explanation given to the client and family of the reason for the rash 3) Notation on an allergy list and notification of the health care provider 4) The need for application of corticosteroid cream to decrease inflammation

3 suspected reaction too substances should be reported to the health care provider and noted on list of possible allergies 1: would be noted, but is not as high a priority 2 and 4: inappropriate

The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? 1) Allowing the client to use abusive language will undermine the authority of the nurse 2) Responding in kind to a client who uses abusive language will perpetuate the behavior 3) Abusive language is one of the behaviors symptomatic of the client's illness 4) The nurse should model acceptable behavior and language for all clients

3 symptoms will respond to treatment 1: inaccurate; doesn't undermine authority of staff 2: shows lack of understanding of cause for client's behavior 4: suggests that using acceptable language will change client's behavior; shows lack of understanding of client's behavior

The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the HCP ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1) Tissue injury after surgery decreases blood glucose 2) Anesthesia acts to increase glycogen stores 3) Being NPO inhibits normal blood glucose control 4) Surgery often leads to insulin dependency

3 temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of IV fluids 1, 2, 4: inaccurate

The nurse evaluates the nutritional intake of an adolescent female client attending camp. The client receives three balanced meals per day and consumes 100% of each meal with an average nutritional intake per meal of 900 calories with 3 mg of iron. The adolescent menstruates monthly and is of average weight for height. Which best describes the adolescent's nutritional intake? 1) Low in calories and high in iron 2) Low in calories and low in iron 3) High in calories and low in iron 4) High in calories and high in iron

3 this client is consuming 2700 calories/day; an adolescent female requires 2,000-2400 kcal/day and a minimum of 15 mg/day of iron intake 1: iron level is low for a menstruating adolescent female 4: exceeds caloric needs by approx 300 calories per day; clients intake is low by approx 6 mg per day

The client comes to the clinic to have a hemoglobin A1C performed. Which client statement indicates to the nurse an understanding of the procedure? 1) This test is performed by using a first voided urine specimen 2) This test needs to be performed in the morning before I eat breakfast 3) This test indicates how well my blood sugar has been controlled the past 2-3 months 4) I must follow my diet carefully for several days before the test

3 when RBCs are being formed, glucose is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5-6% 1: blood sample is needed; can be obtained from a finger stick or a venipuncture 2: timing of test is not important 4: current blood glucose doesn't affect test

The client has orders for cefoxitin 2 g IV piggyback in 100 mL 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is most important for the nurse to take which action? 1) Administer the medication slowly, at 20 to 25 mL/h. 2) Change the primary IV solution. 3) Hang the piggyback infusion bag higher than the primary infusion bag. 4) Obtain an infusion pump prior to administration.

3 when using a gravity drip, piggyback fluid level needs to be higher than primary infusion 1: antibiotic should be administered within 1 hour 2 and 4: unnecessary for safe infusion

The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1) The health care provider is able to directly observe the kidney pelvis 2) An IVP assesses the glomeruli filtration rate 3) The health care provider is able to examine the urinary tract by x-ray 4) Medication is injected into the urinary system

3 x-rays of entire urinary tract taken, evaluates kidney function 1: would involve invasive procedure, such as cystoscopy 2 and 4: not primary purpose

A Miller-Abbott tube is ordered for the client. The nurse knows this tube is inserted for which main reason? 1) Provides an avenue for nutrients to flow past an obstructed area 2) Prevents fluid and gas accumulation in the stomach 3) Administers medications that can be absorbed directly from the intestinal mucosa 4) Removes fluid and gas from the small intestine

4 Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus 1: tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction 2: describes a tube such as Levin or Salem Sump, which decompresses the stomach 3: tube provides for decompression instead of instillation of medications

The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed. 1) The LPN/LVN places the solution 20 inches above the anus 2) The LPN/LVN adjusts the temperature of the solution 3) The LPN/LVN inserts the tube 6 inches. 4) The LPN/LVN positions the client left Sims' position.

4 allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution 1: could cause rapid infusion and possible painful distention of the colon 2: is not feasible during the administrative phase 3: tube should be inserted no more than 4 inches

The nurse cares for the child who is in Buck's traction. The nurse notes the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse takes which action? 1) Records the observation. 2) Encourages the child to move the foot. 3) Covers the colder foot with a sock. 4) Notifies the health care provider.

4 assessment indicates the elastic bandage is too tight and needs readjusting 1: ignores possibility the elastic bandage is too tight 2 or 3: does not relieve the circulation problem

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the best response by the nurse? 1) 11 months of age. 2) 14 months of age. 3) 17 months of age. 4) 20 months of age.

4 average of training begins at 20 months; by 24 months may be able to achieve daytime bladder control 1, 2, and 3: not able to physiologically control sphincters until 18 months of age

The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the most appropriate nursing action if the client's IV infiltrates? 1) Apply warm soaks to the infiltration site, start a new IV, and continue IV medications. 2) Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. 3) Restart the IV and continue the previous medication schedule. 4) Call the health care provider and recommend the IV medication be changed to PO.

4 before a new IV is started on this client, HCP should be called and PO medications receommended 1: continued IV medication may not be necessary based on the current assessment 2: health care provider should be notified if IV medications are not infusing as scheduled 3: client has improved breathing, so IV medications may not be indicated

The nurse provides care for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is most important for the nurse to take which action? 1) Assess drainage from site drains. 2) Observe dressings for signs of excessive bleeding. 3) Elevate the residual limb for no less than 40 hours. 4) Provide cast care on the affected extremity.

4 cast applied to provide uniform compression, prevents pain and contractures 1: drains not usually used with amputations 2: rigid cast dressing frequently used to create a socket for prosthesis 3: elevation of extremity for this length of time is unnecessary; rigid cast dressing prevents swelling

The client is diagnosed with a hiatal hernia. Which information is the nursing assessment most likely to reveal? 1) A bulge in the lower right quadrant. 2) Pain at the umbilicus radiating down into the groin. 3) A burning sensation in the midepigastric area each day before lunch. 4) Reports of awakening at night with heartburn.

4 classic symptoms of hiatal hernia associated with reflux 1 and 2: suggests an inguinal hernia 3: pain usually does not develop during the day with an empty stomach

The client is diagnosed with myasthenia gravis. It is most important for the nurse to consider which action? 1) Prevent accidents from falls as a result of vertigo 2) Maintain fluid and electrolyte balance 3) Control situations that could increase intracranial pressure and cerebral edema 4) Assess muscle groups toward the end of the day

4 client has increased muscle fatigue, needs more assistance toward end of day 1) does not experience vertigo 2) fluid and electrolytes usually not a problem for this client 3) increased intracranial pressure is not associated with myasthenia gravis

The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication? 1) Inability to talk 2) Loss of the gag reflex 3) Inability to open the affected eye 4) Corneal abrasion

4 client will be unable to close eye voluntarily; when cranial nerve VII (facial) is affected, the lacrimal gland will no longer supply secretions that protect the eye 1, 2, and 3: may occur, but nursing care cannot prevent it

The nurse performs ROM exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about ROM? 1) Passive ROM exercises increase muscle strength 2) A full ROM must be completed for the elderly client 3) Exercises should be completed to the point of discomfort 4) ROM assists the elderly to carry out ADLS

4 emphasis should be ROMs that support ADLs 1: inaccurate statement 2: full ROM may not be needed or accomplished without discomfort for an elderly client; ROM may be limited 3: should not be done to point of discomfort

The newborn is diagnosed with fetal alcohol syndrome. The nurse knows which action is an important consideration for this newborn? 1) Prevent iron deficiency anemia 2) Decrease touch to prevent over stimulation 3) Provide feelings via savage to decrease energy expenditure 4) Replace vitamins depleted as a result of poor maternal diet

4 frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function 1: not highest priority 2: infant needs to be held and cuddled due to a poorly developed CNS 3: usually unnecessary

The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement? The client's decreased vision is caused by: 1) bleeding into the inner ocular chamber of the eye 2) gradual separation of the retina from the base of the eye 3) an increase in the size of the vessels in the back of the eye 4) gradual destruction and degeneration of the retina

4 gradual destruction occurs because of deterioration of the retinal vessels 1) complication of postoperative eye surgery or traumatic injury (hyphema) 2: describes a retinal detachment 3: destruction of the vessels, as well as edema, occurs

The client is learning to self-administer insulin. Which observation indicates to the nurse the client needs further teaching? 1) The client draws up the short-acting insulin first, then the intermediate-acting insulin. 2) The client gently rotates the insulin bottle before withdrawing the dose. 3) The client rotates injection sites following the guide on the printed diagram. 4) The client administers the insulin while it is still cold from the refrigerator.

4 insulin should be administered at room temperature; temperature extremes should avoided 1: when mixing short-acting insulin with other types of insulin, the client should draw up the clear (short-acting [regular]) before the cloudy (intermediate-acting) 2: bottle of insulin should never be vigorously shaken, but rather gently mixed 3: imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption

The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the initial priority 1) Provide adequate hygiene and nutrition. 2) Decrease environmental stimuli. 3) Slowly involve the client in unit activities. 4) Administer and monitor sedative and mood-stabilizing medications.

4 is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents 1: is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority 2: decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression 3: this action is inappropriate at this time

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? 1) Jaundice 2) Rash 3) Bruising 4) Cellulitis

4 most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus 1: can develop because of hepatitis B and cirrhosis, may occur in narcotic abusers who use IV drugs 2 or 3: may occur because of the chemicals that are used in cutting the drugs by the client or drug dealer

The nurse cares for the client who has just had a prosthetic hip implant. The nurse places the client in which position? 1) With the affected hip internally rotated and flexed. 2) With the affected hip adducted when turned. 3) In the supine position with the knees elevated 90 degrees. 4) Side-lying with the affected hip in a position of abduction.

4 position of abduction should be maintained 1, 2, 3: flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period

The nurse observes the student nurse care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity? 1) Gives isoniazid to a client with tuberculosis. 2) Administers an IM injection to a client with rubella. 3) Delivers a food tray to a client with hepatitis. 4) Changes the dressing for a client with a draining abscess.

4 requires contact precautions 1: requires airborne precautions, particulate respirator 2: requires droplet precautions; nurse should wear a mask 3: requires standard precautions

The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the ED. The nurse knows the most common reaction of the significant other to a rape victim is reflected in which behavior? 1) Supportive and helpful to the victim 2) Disconnected from and apathetic toward the victim 3) Frustrated and feeling vulnerable, but denying the need for help 4) Emotionally distressed and needing assistance

4 sexual assault by rape is a crisis situation for victim and family members and friends 1: S/O may want to be helpful, however they generally do not have the immediate coping strategies to do so 2: rarely feel disconnected 3: usually family members will need and respond well to psychological intervention

The nurse cares for the elderly client who is admitted with confusion, mood lability, impaired communication, and lethargy. Which order from the health care provider does the nurse question? 1) Dexamethasone suppression test 2) Thyroid studies 3) Drug toxicology screen 4) Trendelenburg test

4 test is used with a client who may have varicose veins, which have no relationship to the symptoms described in this situation 1: may be ordered to determine adrenal gland function 2: may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made 3: may be ordered to see if the client's symptoms are caused by excessive use of medication \s or alcohol

The client with type 1 diabetes asks the nurse why the HCP prescribed short-acting insulin instead of intermediate-acting insulin. Which response by the nurse is best? 1) More injections are required with intermediate-acting than with short-acting insulin 2) Hypoglycemia and hyperglycemia are more common with intermediate-acting insulin 3) Development of eye and kidney damage is less likely with SA insulin 4) Blood glucose levels can be controlled more accurately with SA insulin

4 tighter blood glucose control occur with short-acting insulin, especially initially 1: fewer injections are required with intermediate-acting insulin 2: no change in incidence of hypo/hyperglycemia 3: complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1) Notes subjective data, such as "My breathing is much improved now". 2) Notes objective findings, such as decreased RR and pulse. 3) Consults with the respiratory therapist to determine effectiveness. 4) Auscultates the chest for change or clearing of adventitious breath sounds.

4 to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions 1: subjective data and not as conclusive 2: correct but not as effective 3: not appropriate

Promethazine hydrochloride 25 mg IV push is ordered for the client. Prior to administering this medication, the nurse makes which assessment? 1) The color of the medication solution 2) The client's pulse and temperature 3) The time of the last analgesic dose the client received 4) The patency of the client's vein

4 very important to determine absolute patency of the vein; extravasation will cause necrosis 1: is true, but not as high a priority 2: no relevance to the question asked 3: medication is used as an adjunct to analgesics but has no analgesic activity itself

The parent of a toddler recovering from surgery is concerned because the client is restless and overactive. Which action will the nurse take? 1) Direct the LPN/LVN to obtain the client's vital signs. 2) Ask the parent if the client's sutures are still intact. 3) Tell nursing assistive personnel to take the client for a 4) Check to see when pain medication was last provided.

4 young children typically become restless and overactive in response to pain. grimacing, clenching teeth, rocking, and aggressive behavior may also be observed 1:There is no indication that there are any problems with the client's vital signs. 2: It is not the parent's responsibility to assess the surgical site and condition of the sutures. 3: The client should be assessed first before ambulating.