NUR 395 C.O.T.A.C FINAL EXAM

A nurse is teaching a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include in the teaching? A. "Extended periods of immobility increase your risk of osteoporosis." B. "Prolonged periods of sun exposure increase your risk of osteoporosis." C. "Eating a diet high in protein can reduce your risk of osteoporosis." D. "Corticosteroid therapy will reduce your risk of osteoporosis."

A. "Extended periods of immobility increase your risk of osteoporosis."

A nurse is providing teaching to a client with hypertension and type 1 diabetes mellitus who has a new prescription for metoprolol. Which of the following statements by the client indicates an understanding of the teaching? A. "I might have difficulty recognizing when my blood sugar is low." B. "I will have a lower risk of developing an infection while I take this medication." C. "I should be concerned about losing excess weight while I take this medication." D. "I could have more problems with high blood sugar while taking this medication.

A. "I might have difficulty recognizing when my blood sugar is low."

A nurse is teaching a client who has a prescription for scopolamine patches for the treatment of motion sickness. Which of the following client statements should indicate to the nurse that the teaching has been effective? A. "I should apply this patch behind my ear." B. "This patch should be replaced every 7 days." C. "Before putting on my patch, I should wipe the area with an alcohol swab." D. "I can use a second patch if a single patch is not effective."

A. "I should apply this patch behind my ear."

A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when I'm in my child's room." D. "I will apply lotion to my child's peeling hands."

A. "My child may take aspirin for his joint pain."

A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which of the following pieces of information should the nurse give the client prior to the procedure? A. "You can have a mild sedative before the procedure." B. "You'll have to lie still on your back for 15 to 20 min." C. "You can't have this test if you've had cataract surgery." D. "Your exposure to radiation will be minimal."

A. "You can have a mild sedative before the procedure."

A nurse is providing discharge instructions about calcium supplements to an older adult female client who has osteoporosis and recently underwent a repair of a fracture in her right hip. which of the following instructions should the nurse include? A. "You should take your calcium supplement with a large glass of water." B. "You should increase your intake of grain cereals while taking calcium supplements." C. "You should take at least 2600 mg of calcium supplements daily." D. "you will not need to take vitamin D with your calcium supplement after menopause."

A. "You should take your calcium supplement with a large glass of water."

A nurse is preparing to administer amlodipine to a client who has hypertension. The nurse should plan to monitor the client for which of the following adverse effects of the medication? (Select all that apply.) A. Dizziness B. Pale appearance C. Palpitations D. Abdominal pain E. Peripheral edema

A. Dizziness C. Palpitations E. Peripheral edema * The nurse should monitor this client who is taking amlodipine for dizziness, palpitations, and peripheral edema as adverse effects of the medication. The nurse should advise the client to avoid activities that require alertness until the effect of the medication is known and to notify the provider if any of these adverse effects occur

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

A. Elevate the affected leg * The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? A. Exercise B. Pregnancy C. Infection D. Sunlight

A. Exercise

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C Heightened immune response D. Bleeding tendencies

A. Hyperglycemia * Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia.

A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the clients breast cancer risk? (Select all that Apply) A. Increased Breast Density. B. A BMI of 32. C. Having given birth to 5 children. D. Undergoing hormonal replacement therapy for 10 years. E. Having 1-2 alcoholic drinks per week.

A. Increased Breast Density. B. A BMI of 32. D. Undergoing hormonal replacement therapy for 10 years.

A nurse is performing skin assessments for a group of older adult clients. Which of the following findings should the nurse identify as a benign, age-related skin change commonly seen in this population? A. Liver spots B. Nevi C. Atopic dermatitis D. Psoriasis

A. Liver spots

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hr B. Limit the client's daily fluid intake until he is no longer incontinent C. Request a prescription for an indwelling urinary catheter from the client's provider D. Ambulate the client to the bathroom every 30 min

A. Offer the client a bedpan every 2 hr

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? A. Offering the client a diet high in fluid and fiber B. Encouraging active range of motion of the affected leg C. Removing the weights prior to repositioning the client D. Inspecting pin sites every 24 hr for drainage

A. Offering the client a diet high in fluid and fiber

A nurse is caring for a client who developed hypoglycemia following an insulin injection. The client is conscious and responds appropriately to verbal stimuli. Which of the following medications should the nurse plan to administer first? A. Oral glucose tablet B. 50% dextrose intravenously C. Glucagon intramuscularly D. Epinephrine intravenously

A. Oral glucose tablet * Evidence-based practice indicates that a client who has mild hypoglycemia and is conscious and able to swallow should receive an oral agent such as an oral glucose tablet. If the client is unresponsive to the oral glucose tablet, another, more invasive form of treatment can be initiated

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable Fetal movement B. Chadwick's sign C. Positive Pregnancy test D. Amenorrhea

A. Palpable Fetal movement

A nurse is teaching a community group who lives near a nuclear power plant about safety precautions related to radiation exposure. A client asks, "Isn't there something we should have on hand in case of a nuclear disaster?" The nurse should recognize that the client is referring to which of the following substances? A. Potassium iodide B. Potassium cyanide C. Ciprofloxacin D. Atropine

A. Potassium iodide

A nurse working in a community health center is completing an assessment of an older adult female client. Which of the following findings should the nurse identify as a priority? A. Rales heard in the bases of the lungs B. Constipation C. Urinary frequency D. Painful intercourse

A. Rales heard in the bases of the lungs

A nurse is caring for a client with diabetic ketoacidosis who has a prescription for an intravenous infusion of insulin. The nurse should document that which of the following types of insulin was administered intravenously to treat ketoacidosis? A. Regular insulin B. Insulin lispro C. Insulin aspart D. Insulin glargine

A. Regular insulin

A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? A. Shakiness B. Urinary frequency C. Dry mucous membranes D. Excess thirst

A. Shakiness *A client who has hypoglycemia can experience early manifestations of shakiness, as well as fatigue, a headache, difficulty thinking, sweating, and nausea

A nurse is determining a client's risk of developing osteoporosis. The nurse should identify which of the following as risk factors for bone loss? (Select all that apply.) A. Small body frame B. Hypertension C. African-American ethnicity D. Low vitamin D intake E. Smoking

A. Small body frame D. Low vitamin D intake E. Smoking

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

A. Ulceration

A nurse is updating the plan of care for a client who is to receive total parenteral nutrition (TPN). Which of the following actions should the nurse include in the plan? (Select all that apply) A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr. C. Apply A new dressing to the client's IV site every 5 days. D. Change the IV tubing every 24 hr. E. Infuse the TPN through a peripheral IV site.

A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr. D. Change the IV tubing every 24 hr.

A nurse is teaching a client who had a vaginal hysterectomy with a bilateral oophorectomy. Which of the following pieces of information should the nurse include in the teaching? A. "Plan to use some type of birth control for up to 6 weeks after surgery. " B. "Use a water based lubricant when having sexual intercourse." C. "Expect to have an increase in bloody vaginal drainage during the first 10 days after surgery." D. Plan to start some type of aerobic exercise such as swimming within a week after surgery."

B. "Use a water based lubricant when having sexual intercourse."

A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? A. "You will need to continue to use some form of birth control for 6 months." B. "You might experience manifestations of menopause." C. "Do not lift anything heavier than 15 lb." D. "Pain or burning with urination is an expected outcome of this surgery."

B. "You might experience manifestations of menopause."

A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? A. "You will need to continue to use some form of birth control for 6 months." B. "You might experience manifestations of menopause." C. "Do not lift anything heavier than 15 lbs." D. "Pain or burning with urination is an expected outcome of this surgery."

B. "You might experience manifestations of menopause."

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available from the pharmacy. B. Check the client's capillary blood glucose level every 4 hr. C. Obtain the client's weight each week D. Change the IV tubing every 3 days.

B. Check the client's capillary blood glucose level every 4 hr.

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

B. Cheyne-Stokes * Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

A nurse is caring for a client who has Alzheimer's disease and a prescription for memantine. Which of the following laboratory findings should the nurse identify as a contraindication to receiving this medication? A. Alanine aminotransferase (ALT) 60 units/L B. Creatinine clearance 35 mL/min C. HbA1c 5% D. BMI 31

B. Creatinine clearance 35 mL/min * The nurse should identify that creatinine clearance is a value of the glomerular filtration rate (GFR) that determines the kidney's ability to filter waste. A creatinine clearance of 35 mL/min is outside of the expected reference range and reveals moderate renal impairment. Memantine is excreted by the kidneys, and a decreased clearance occurs in moderate renal impairment. Therefore, this finding is a contraindication to receiving the medication.

A nurse is reviewing the medical record of a client who is requesting a prescription for sildenafil citrate. Which of the following data in the client's record should the nurse identify as a contraindication to the use of this medication? A. Diabetes Mellitus. B. Current use of isosorbide to treat heart failure. C. Eyeglasses for presbyopia. D. Osteoarthritis.

B. Current use of isosorbide to treat heart failure.

A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect? A. Increased saliva production B. Decreased sense of taste C. Increased sense of smell D. Decreased chest wall rigidity

B. Decreased sense of taste * When assessing an older adult client, the nurse should expect a decreased sense of taste due to atrophy of the taste buds. This can increase the client's risk for poor intake, resulting in less than optimal nutrition.

A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiological changes can contribute to the development of type 2 diabetes? A. Increased production of insulin by the pancreas B. Decreased sensitivity to the circulating insulin C. Increased rate of glucose metabolism D. Decreased release of glycogen by the liver

B. Decreased sensitivity to the circulating insulin * The pancreas in older adult clients demonstrates reduced tissue sensitivity to circulating insulin, leading to an increased risk of developing type 2 diabetes mellitus

A nurse is teaching a group of healthy older adult clients about expected age-related changes and sexual response. Which of the following changes should the nurse include as an age-related change? A. Decreased refractory time B. Decreased vaginal lubrication C. Loss of female clients' orgasm ability D. Premature ejaculation

B. Decreased vaginal lubrication * The nurse should inform clients that decreased vaginal secretions is an expected age-related change in older adult female clients. Vaginal dryness might lead to painful intercourse, which clients can manage with the use of water-soluble lubricants during intercourse.

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? A. Kussmaul respirations B. Diaphoresis C. Decreased skin turgor D. Ketonuria

B. Diaphoresis * A client who has a blood glucose level below 70 mg/dL will exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion.

A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply.) A. Bradycardia B. Diaphoresis C. Deep, rapid respirations D. Palpitations E. Shakiness

B. Diaphoresis D. Palpitations E. Shakiness * Diaphoresis, palpitations, and shakiness are sympathetic nervous system responses to hypoglycemia.

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum

B. Epidermis

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo B. Epistaxis C. Exophthalmos D. Spondylolisthesis

B. Epistaxis * Epistaxis (a nosebleed) is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial flushing, and fainting

A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to the correct alignment in bed B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely C. Lift the rope off the pulley while the client rocks back and forth to reposition himself D. Lift the weight manually while another staff member moves the client up in bed

B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely

A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations? A. Dementia B. Hypoglycemia C. Infection D. Transient ischemic attack

B. Hypoglycemia * Evidence-based practice indicates the nurse should first check the client for hypoglycemia by drawing a blood glucose level. A client who has hypoglycemia can have slurred speech, disorientation, weakness, and confusion near meal time each day because regular insulin peaks in 2 to 4 hours, causing a drop in the client's blood glucose. Other manifestations of hypoglycemia include irritability, mental confusion, double vision, hunger, tachycardia, diaphoresis, and palpitations

A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should recommend which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster

B. Meningococcal polysaccharide

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A nurse is providing teaching to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following adverse effects of metformin should the nurse instruct the client to watch for and report to the provider? A. Weight gain B. Myalgia C. Hypoglycemia D. Severe constipation

B. Myalgia * Myalgia, malaise, somnolence, and hyperventilation are manifestations of lactic acidosis, which rarely occur while taking metformin due to the blockage of lactic acid oxidation. The nurse should instruct the client to report these findings promptly to the provider.

A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. Sensation of heat on the surface of the cast B. Paresthesias of the extremity C. Pruritus of the extremity D. Musty odor noted from cast materials

B. Paresthesias of the extremity

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in the semi-Fowler's position C. Cleanse the skin around the tube site D. Aspirate the tube for residual contents

B. Place the client in the semi-Fowler's position

A nurse is speaking to a community group about the diagnosis and treatment of clients who have Alzheimer's disease. The nurse should conclude that the group requires further teaching when a member identifies which of the following findings as a manifestation of Alzheimer's disease? A. Impaired judgment B. Sudden confusion C. Personality change D. Remote memory loss

B. Sudden confusion * The nurse should clarify that a client who has Alzheimer's disease is expected to exhibit confusion that develops slowly over months. Clients who have delirium exhibit sudden confusion.

A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected finding of peripheral neuropathy. A. Thinning of the scalp hair B. Tingling of the hands and feet C. Reduced ability to concentrate. D. Sores in the mucous membranes

B. Tingling of the hands and feet

A nurse is providing teaching to a client who has a prescription for ciprofloxacin following exposure to anthrax. Which of the following statements by the client indicates that further teaching is required? A. "I will limit my intake of coffee, tea, and carbonated beverages." B. "I will wear a large-brim hat and long sleeves if I am out in the sun." C. "I will take the ciprofloxacin with an antacid if I get an upset stomach." D. "I will avoid taking ciprofloxacin along with dairy products."

C. "I will take the ciprofloxacin with an antacid if I get an upset stomach."

A nurse is providing discharge teaching about foot care to a client who has diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I can use a heating pad on my feet to keep them warm." B. "I can go barefoot as long as I stay inside the house." C. "I will wash my feet daily and apply lotion, except between my toes." D. "I will trim my toenails every morning by rounding the corners.

C. "I will wash my feet daily and apply lotion, except between my toes." * Diabetic neuropathy is a risk factor for amputation of an extremity. The client should inspect the feet daily in order to recognize early injury. The client should also clean the feet daily with mild soap and warm water. Lotion is applied to the feet to prevent drying and cracking. However, lotion should not be applied between the toes, as this can provide a moist environment that favors bacterial growth.

A nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."

C. "Keep the cast above the level of your heart."

A nurse is teaching a client who has a prescription for doxycycline for the treatment of a Helicobacter pylori infection. Which of the following instructions should the nurse include in the teaching? A. "Take this medication with meals to decrease gastrointestinal upset." B. "Continue this medication if you become pregnant." C. "Wear protective clothing while in the sun." D. "Expect to have severe diarrhea while taking this medication."

C. "Wear protective clothing while in the sun."

A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL. C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%

C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients should the nurse attend to first? A. A client who is receiving metoclopramide and reports diarrhea B. A client who is receiving tamsulosin and reports feeling dizzy C. A client who is receiving cephalexin and reports dyspnea D. A client who is receiving erythromycin and reports epigastric pain

C. A client who is receiving cephalexin and reports dyspnea

A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administer IV fluid replacement D. Administer tetanus prophylaxis

C. Administer IV fluid replacement

A nurse at a long-term care facility is planning care for a client who has Alzheimer's disease and wanders at night. Which of the following interventions should the nurse include in the plan? A. Place the client in wrist restraints at night. B. Request a prescription for a psychotropic medication. C. Assign the client to a room closer to the nurse's station. D. Keep the television on at night.

C. Assign the client to a room closer to the nurse's station. * The nurse should place the client who wanders in a room that allows close observation. The nurse should provide a safe place to walk for clients who wander and supervision when ambulating

A nurse is planning care for a client who is postoperative following a radical mastectomy. which of the following interventions should the nurse include in the plan? A. Rest the arm on the affected side on the bed when the client is sleeping. B. Instruct the client to keep the affected arm flexed when ambulating C. Begin exercises with the client 1 day after the procedure. D. Maintain the client on bed rest for 2 days after the procedure.

C. Begin exercises with the client 1 day after the procedure.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg

C. Chest petechiae

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia

C. Decreased cardiac output

A nurse is caring for an older adult client. Which of the following physiological changes associated with aging can affect medication dosing for this client? A. Increased glomerular filtration rate B. Decreased body fat C. Decreased gastric motility D. Decreased gastric pH

C. Decreased gastric motility * Decreased gastric motility causes medications to remain in the digestive tract for longer periods of time, leading to slower absorption of the medication. The provider might have to allow a longer time for medication onset and peak by extending the length of time between doses.

A nurse is caring for an older adult client who has pneumonia. Which of the following physiological changes associated with aging places the client at risk of pneumonia? A. Decreased anterior-posterior diameter B. Increased diameter of the small airways C. Decreased number of cilia D. Increased alveolar surface area

C. Decreased number of cilia * A decreased number of cilia is a physiological change associated with aging. This, along with a less effective cough, reduces the efficiency of the normal defense mechanisms for clearing the airway, putting the client at an increased risk of infection such as pneumonia

A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output

C. Deep, rapid respirations

A nurse is caring for a client who was newly diagnosed with breast cancer that has metastasized into the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kübler-Ross' grief theory? A. Anger B. Bargaining C. Denial D. Depression

C. Denial

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hr. Which of the following actions should the nurse take? A. Instruct the client to attempt to void around the indwelling urinary catheter B. Increase the rate of irrigation fluid instillation C. Irrigate the indwelling urinary catheter with a syringe D. Prepare to administer a diuretic

C. Irrigate the indwelling urinary catheter with a syringe

A nurse is monitoring a client with pneumonia who has received penicillin G intramuscularly (IM). Which of the following findings should the nurse plan to evaluate first? A. Pain at the injection site B. Prolonged motor dysfunction C. Laryngeal edema D. Temperature 37.6°C (99.7°F)

C. Laryngeal edema

A nurse is interviewing an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use? A. Avoid directly asking the client if she has been abused B. Use a confrontational approach C. Maintain a nonjudgmental tone D. Avoid being in the room alone with the client

C. Maintain a nonjudgmental tone * The nurse should use a nonjudgmental tone to promote trust and communication

A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects? A. Thrombophlebitis B. Hyperactive reflexes C. Muscle weakness D. Hypoglycemia

C. Muscle weakness * Chlorothiazide is a thiazide diuretic used to treat hypertension and congestive heart failure. It promotes the excretion of water, sodium, and potassium and can cause hypokalemia. Manifestations of hypokalemia include muscle weakness, muscle cramps, and dysrhythmias.

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis * Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult day care facility

C. Respite care * Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance

A nurse is teaching self-administration of NPH insulin to a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include? A. Alternate injecting doses between the abdomen and the thigh B. Shake the vial before withdrawing the dosage C. Rotate injection sites within the same area D. Discard the vial if the insulin is cloudy

C. Rotate injection sites within the same area * To prevent lipodystrophy, the client should rotate injection sites and keep them about 2.5 cm (1 in) apart within the same anatomical area.

A nurse is teaching a client about physiological changes that can occur with menopause. which of the following changes should the nurse include? A. Urinary Hesitancy B. Hematuria C. Stress Incontinence D. Increased Vaginal Moisture

C. Stress Incontinence

A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. Which of the following assessments describes the incision? A. The incision is showing early signs of infection. B. The incision is showing early signs of dehiscence. C. The incision is showing signs of healing without complications. D. The incision is showing signs of developing a fistula.

C. The incision is showing signs of healing without complications.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted lesions B. A large, tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. A fluid-filled vesicular rash in the genital region

C. Unilateral, localized, nodular skin lesions

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? A. Output equal to the instilled irrigant B. Client report of bladder spasms C. Viscous urinary output with clots D. Client report of a strong urge to urinate

C. Viscous urinary output with clots

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that which of the following nutrients (in addition to protein) promotes wound healing? A. Vitamin B1 B. Calcium C. Vitamin C D. Potassium

C. Vitamin C

A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D

C. Vitamin C

A nurse is providing nutrition education to a client who has osteomalacia. The nurse should identify that this condition is caused by a deficiency in which of the following nutrients? A. Fluoride B. Vitamin A C. Vitamin D D. Phosphorus

C. Vitamin D

A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? A. With the leg on the affected side adducted B. With the hip externally rotated on the affected side C. With the leg on the affected side abducted D. With the hip flexed to 90° on the affected side

C. With the leg on the affected side abducted

A nurse is providing teaching for a client who has a new prescription for nitroglycerin administered through a transdermal patch. Which of the following client statements indicates an understanding of the teaching? A. "I need to wear the patch continuously for it to be effective." B. "I will stop using the patch immediately if it gives me a headache." C. "I should change the patch whenever I have chest pain." D. "I need to rotate the location of my patch every few days.

D. "I need to rotate the location of my patch every few days.

A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following client statements indicates an understanding of the information? A. "I will not need to have a urinary catheter following this procedure." B. "I will expect my urine to be cloudy after having this procedure." C. "At least I won't have leakage of urine after having this procedure." D. "I will feel the urge to urinate following this procedure."

D. "I will feel the urge to urinate following this procedure."

A nurse is caring for an adolescent client who was recently diagnosed with testicular cancer. When the nurse asks the client a question, he angerly spits in the nurses face. Which of the following responses should the nurse provide? A. "I will come back to change your linens when you are feeling better." B. "Who do you think you are to treat me like that?" C. "Why did you spit in my face?" D. "You seem to be very upset."

D. "You seem to be very upset."

A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the high protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices

D. 1/2 cup of peanut butter with apple slices * Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which promotes the healing process.

A nurse is teaching a client how to perform a breast self examination (BSE). The nurse should identify which of the following findings as an indication of breast cancer. A. Lumps that are mobile and tender on palpation prior to a menstrual period. B. Multiple round masses that are tender and found in both breasts. C. Bilaterally darkened areolas. D. A nontender, hard lump that is palpated in a breast.

D. A nontender, hard lump that is palpated in a breast.

A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. Which of the following actions should the nurse take? A. Monitor the client's liver function while taking this medication B. Increase the dosage of this medication every 72 hr C. Offer the client a PRN NSAID while taking this medication D. Administer the medication at bedtime

D. Administer the medication at bedtime * Donepezil is used to treat the manifestations of mild to moderate Alzheimer's disease. The nurse should administer this medication at bedtime to reduce the risk of injury due to bradycardia and syncope.

A nurse is caring for a client who has schizophrenia and is being discharged from an acute mental health setting. Which of the following should be included in the discharge plan? A. Refer the client to respite care services B. Provide a list of primary preventive mental health groups C. Enroll the client in a 12-step program D. Contact an intensive outpatient program

D. Contact an intensive outpatient program * A client who has received in-patient treatment for schizophrenia can benefit from an intensive outpatient program. These programs allow clients to receive step-down care similar to what was provided in the inpatient setting to stabilize their condition further.

A nurse is assessing an older adult client. Which of the following findings should the nurse report to the provider? A. Decreased cough reflex B. Decreased urinary bladder capacity C. Decreased sebum production D. Decreased spinal column movement

D. Decreased spinal column movement

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). After the nurse discontinues the client's urinary catheter, which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Report of burning upon urination C. Stress incontinence D. Decreased urine output

D. Decreased urine output

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive Thirst C. Fever D. Diaphoresis

D. Diaphoresis

A nurse is working in the triage area of an emergency department. Which of the following activities is unlikely to be the nurse's responsibility in this setting? A. Fostering positive public relations for the facility B. Performing a comprehensive client assessment C. Preventing cross-contamination of infectious clients D. Educating a client and his family members

D. Educating a client and his family members

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

D. Encourage the child to use an incentive spirometer

A nurse is caring for a client who is 12 hours postoperative following a total hip arthroplasty. Which of following medications should the nurse anticipate administering to this client to prevent deep vein thrombosis (DVT)? A. Aspirin B. Warfarin C. Ticagrelo D. Enoxaparin

D. Enoxaparin * The nurse should anticipate the administration of enoxaparin for a client who is 12 hours postoperative following surgery. Enoxaparin is low-molecular-weight (LMW) heparin that is used to prevent a DVT by inhibiting the effects of antithrombin and thrombin

A nurse is caring for a client who has a vitamin K deficiency. Which of the following manifestations should the nurse expect? A. Irregular bone formation B. Abnormal movements C. Blurred vision D. Excessive bruising

D. Excessive bruising

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.

D. Granulation tissue fills the wound during healing.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin

D. Halo of erythema on the surrounding skin

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

D. Impaired circulation

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure

D. Infection acquired from a diagnostic procedure

A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of malignant melanoma? A. Rough, dry, scaly lesion B. Firm nodule with crusting C. Pearly papule with ulcerated center D. Irregularly shaped lesion with blue tones

D. Irregularly shaped lesion with blue tones

A nurse is preparing a plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invasive devices should the nurse expect the client to have? A. Chest Tube B. Indwelling urinary catheter C. Nasogastric Tube D. Jackson-Pratt drain

D. Jackson-Pratt drain

A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the following instructions should the nurse include in the teaching? A. Apply aluminum acetate solution compresses to the lesions B. Apply hydrocortisone cream to the lesions twice daily C. Seal nonwashable toys in a plastic bag for 2 weeks D. Leave the medicated shampoo on the scalp for 5 to 10 minutes

D. Leave the medicated shampoo on the scalp for 5 to 10 minutes

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following pieces of information should the nurse include in the teaching? A. Place abstract pictures on the wall in the client's room B. Provide music for the client using headphones C. Reorient the client to reality frequently D. Limit choices offered to the client

D. Limit choices offered to the client * Choices should be limited for a client who has stage II AD to reduce confusion and frustration

A nurse is assessing a client who has several risk factors for osteoporosis. Which of the following findings indicates that the client requires further evaluation for this disorder? A. Leg cramps with exercise B. Stress incontinence C. Abdominal distention D. Lower back pain

D. Lower back pain

A nurse is preparing a client who is scheduled for a hysterotomy for transport to the operating room. The client states she no longer want to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation D. Notify the provider of the client's decision.

D. Notify the provider of the client's decision.

A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr D. Place the child on a pressure-reduction mattress

D. Place the child on a pressure-reduction mattress

A nurse is caring for a female adult client who is experiencing menopause and has a prescription for estrogen along with progestin. The nurse should identify that the provider has prescribed these medications for which of the following reasons? A. Long-term use to reduce the risk of breast cancer B. Short-term use to stimulate the endometrium C. Long-term use to prevent osteoporosis D. Short-term use to control urogenital atrophy

D. Short-term use to control urogenital atrophy

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? A. Blood urea nitrogen (BUN) B. Blood glucose C. Urine ketones D. Specific gravity

D. Specific gravity * Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, an infection, or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

D. Stop the medication infusion

A nurse is planning care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? A. Curettage B. External radiation therapy C. Regional chemotherapy D. Surgical excision

D. Surgical excision

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? A. The client has a new tattoo. B. The client is unable to sit upright. C. The client has a history of peripheral vascular disease. D. The client has a pacemaker.

D. The client has a pacemaker.

A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? A. The client requires assistance with eating. B. The client independently manages personal finances. C. The client has bladder incontinence. D. The client is able to identify the names of family members

D. The client is able to identify the names of family members * The nurse should expect this client who has Stage 4 Alzheimer's disease to recognize and identify family members. Clients who have Alzheimer's disease maintain this ability until Stage 6.

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long B. Remove the stocking once per day C. Bunch and pull the stocking halfway up the calf D. Turn the stocking inside out up to the heel before applying

D. Turn the stocking inside out up to the heel before applying

A nurse is preparing to administer 100 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take? A. Verify with the provider about giving insulin glargine at 1700 B. Ensure the insulin glargine is a cloudy suspension C. Request a prescription for giving insulin glargine twice daily D. Use separate syringes for administering insulin glargine and NPH insulin

D. Use separate syringes for administering insulin glargine and NPH insulin * The nurse should not mix insulin glargine with any other insulin. The nurse should administer the NPH insulin and insulin glargine separately.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. Which of the following actions should the nurse perform? A. Change the tubing every 12 hr. B. Check the client's blood glucose every 8 hr. C. Apply a new dressing to the IV site every 76 hr. D. Weigh the client daily.

D. Weigh the client daily.

A nurse is teaching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia C. Otitis media D. Osteomyelitis

A. Hydrocephalus

A nurse is assessing a client who has binge-eating disorder. Which of the following findings should the nurse expect? A. Amenorrhea B. Abdominal pain C. Restricted caloric intake D. Frequent use of laxatives

B. Abdominal pain * The nurse should expect the client who has binge-eating disorder to report problems with abdominal pain due to the gastrointestinal dilation that results from eating excessive volumes of food

A nurse is caring for a child who received penicillin IM 15 minutes ago. The child is now irritable and restless. Which of the following actions should the nurse take first? A. Administer diphenhydramine B. Assess for laryngeal edema C. Initiate hourly urine output monitoring D. Give epinephrine IV push

B. Assess for laryngeal edema

A nurse is discussing medication administration for an older adult client with a newly licensed nurse. Due to physiological changes of aging, older adult clients may need dosage adjustments because of an increase in which of the following parameters? A. Total body water B. Body fat C. Splanchnic blood flow D. Gastric emptying

B. Body fat *Aging causes physiological changes in all organ systems. Tissue composition changes the nurse should be aware of include an increase in adipose tissue, a decrease in lean body mass, and a decrease in total body water. The increase in fatty tissue causes increased storage of lipid-soluble medications and lowers the plasma levels of those medications

A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? A. Inspect the client's skin underneath the boot every 12 hr B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr C. Remove the weights from the traction while repositioning the client in bed D. Loosen the ropes if the client reports muscle spasms in the affected extremity

B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr

A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? A. Hunger B. Increased urination C. Cold, clammy skin D. Tremors

B. Increased urination * Increased urination is a manifestation of hyperglycemia due to a deficiency of insulin, which can lead to osmotic diuresis.

A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? A. Hypoactive bowel sounds B. Indwelling urinary catheter output of 25 mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site

B. Indwelling urinary catheter output of 25 mL/hr

A community health nurse is visiting the home of an older adult client and her caregiver. The client has excoriations to her wrists and ankles. Which of the following actions should the nurse take first? A. Refer the caregiver to a support group B. Interview the client in private C. Document the client's wounds D. Contact adult protective service

B. Interview the client in private * The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds upon the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. The nurse should interview the client in private to gain information about possible abuse because the client may be reluctant to talk with the caregiver present

A nurse is admitting a client who is scheduled for a biopsy of a testicular mass. The client asks, "do you think the doctor will find cancer?" which of he following responses should the nurse make? A. Most tumors in the testicles are benign. B. It must be difficult for you not to know what the doctor will find. C. I think you should discuss this with your doctor. D. "Why are you worried about cancer."

B. It must be difficult for you not to know what the doctor will find.

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? A. Basal cell carcinoma B. Melanoma C. Actinic keratosis D. Squamous cell carcinoma

B. Melanoma

A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? A. Begin monthly breast self examinations at age 40. B. Have a clinical breast examination each year after the age of 30. C. Begin annual mammograms at age 40. D. Have a breast magnetic resonance imaging every 5 years after age 50.

C. Begin annual mammograms at age 40.

A nurse in a provider's office is assessing a client who reports taking a dietary supplement to reduce hot flashes related to menopause. Which of the following supplements should the nurse expect the client to report taking? A. Flaxseed B. Ginkgo Biloba C. Black Cohosh D. St. John's Wort

C. Black Cohosh

A nurse is caring for a client who states "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Positive serum pregnancy test B. Amenorrhea C. Fetal heart tones auscultated by Doppler D. Chadwick sign

C. Fetal heart tones auscultated by Doppler

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator

C. Hearing aids

A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss

C. Infection * The nurse should instruct the client to avoid contact with people who are ill and monitor for manifestations of an infection such as a fever or a sore throat. Prednisone can suppress the client's immune response and mask the manifestations of an infection.

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? A. Suggest the client talk with someone who has survived breast cancer B. Encourage the client not to give up C. Support the client's decision D. Refer the client to a counselor

C. Support the client's decision

A nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include? A. "Common sites for an injection of epinephrine are the fatty tissue found in the upper arm and in the lower abdomen." B. "Administer epinephrine prior to giving your child peanut products in the future." C. "No further treatment is needed after injecting the epinephrine." D. "You will need to increase the dosage as your child gains weight."

D. "You will need to increase the dosage as your child gains weight."

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? A. "You will need to apply a cold pack to the site 3 times a day." B. "Your provider might ask you to walk frequently to increase circulation to the area." C. "You will need to limit your consumption of high-protein foods." D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

A nurse is caring for a school-age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hr during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the child's involved joints every 4 hr. D. Place the child on a pressure-reduction mattress

D. Place the child on a pressure-reduction mattress

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesion

D. Reddish-purple skin lesion

A nurse is performing an assessment on an older adult client who has chronic pain. Which of the following effects of unrelieved pain should the nurse identify as a priority finding to report? A. Impaired mobility B. Decreased independence C. Decreased self-esteem D. Impaired socialization

A. Impaired mobility

A nurse is reviewing the medical record of a client. The medication administration record shows the client is taking clopidogrel. Which of the following events should the nurse expect in the client's medical history? A. Recent myocardial infarction B. History of hemorrhagic stroke C. Current outbreak of psoriasis D. History of hypertension

A. Recent myocardial infarction

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? A. Urine negative for ketones B. Distended neck veins C. Kussmaul respirations D. Elevated blood pressure

C. Kussmaul respirations

A nurse is caring for a client who reports crushing chest pain. The nurse reviews the client's ECG results and notes ST changes. Which of the following medications should the nurse administer? A. Simvastatin B. Furosemide C. Nitroglycerin D. Sildenafil

C. Nitroglycerin

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound

C. Surgical incision

A nurse is reviewing the medical record of a client who has postmenopausal osteoporosis and a prescription for raloxifene. Which of the following findings in the client's medical record should the nurse identify as a contraindication to receiving this medication? A. Breast cancer B. History of deep-vein thrombosis (DVT) C. Allergy to calcitonin D. Current diagnosis of cholecystitis

B. History of deep-vein thrombosis (DVT)

A nurse is providing teaching to a client who is scheduled to start taking FINASTERIDE. Which of the following statements by the client indicates an understanding of the teaching? A. "I will see improvement in my symptoms within a week." B. "I can expect increased libido with this medication." C. "I should see a decrease in my PSA levels." D. "I must take this medication within 60 min of sexual activity.

C. "I should see a decrease in my PSA levels."

A nurse is preparing to administer raloxifene to a client. Which of the following conditions is a contraindication for the administration of this medication? A. Osteoporosis B. Hyperthyroidism C. Myocardial infarction D. Deep-vein thrombosis

D. Deep-vein thrombosis

After a disaster plan is enacted, a nurse in a pediatric unit is asked to prepare a list of clients who can be discharged home due to a local incident involving many children. Which of the following clients should the nurse place on the potential discharge list? (Select all that apply.) A. A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol B. A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics D. A toddler with a ventricular septal defect and bronchiolitis who is on 28% oxygen by oxyhood E. An adolescent client who is 1 day postoperative following scoliosis repair and is on a PCA pump

A. A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol B. A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement

A. Add gestures when speaking with the client *The nurse should use gestures when speaking with the client to increase the client's understanding of the conversation

A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion B. Give potassium as a rapid IV bolus C. Administer 3 units of ultralente insulin subcutaneously D. Obtain an HbA1c level stat

A. Administer 5% dextrose in 0.9% sodium chloride

A nurse is caring for a client who has a new prescription for TAMOXIFEN. The nurse should recognize that TAMOXIFEN has which of the following therapeutic effects? A. Anti-Estrogenic B. Antimicrobial C. Androgenic D. Anti-Inflammatory

A. Anti- Estrogenic

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma

A. Aspiration of water * The client should be careful during bathing and showering and should avoid swimming due to the risk of aspiration of water. The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway.

A nurse is administering intermittent IV antibiotic therapy for a client who has Alzheimer's disease. The client repeatedly attempts to remove the IV access line during the medication administration. Which of the following actions should the nurse take? A. Assign an assistive personnel to remain with the client during the medication administration. B. Call the provider and request a prescription for an oral antibiotic. C. Give the client a PRN sedative 30 min before the IV medication is scheduled. D. Place bilateral wrist restraints on the client during the antibiotic infusion.

A. Assign an assistive personnel to remain with the client during the medication administration.

A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals

A. Attach a latex allergy alert identification band

A nurse in the emergency department is caring for a client who has a fruity breath odor, a dry mouth, and extreme thirst. Which of the following assessments should the nurse make? A. Blood glucose level B. Pupillary reaction to light C. Deep tendon reflexes D. Liver function tests

A. Blood glucose level

A nurse is assessing a client who is 4 hr postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect? A. Blood-tinged urine in the drainage bag B. Catheter tubing coiled at the client's side C. Client report of severe bladder spams D. Urinary output of 20 mL/hr

A. Blood-tinged urine in the drainage bag

A nurse is caring for 4 clients who are scheduled for diagnostic tests. For which of the following tests should the nurse obtain written consent from the client? A. Cerebral arteriogram B. Magnetic resonance imaging (MRI) C. Computed tomography (CT) scan D. Carotid ultrasound

A. Cerebral arteriogram

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. Lower medial quadrant of the buttock near the coccyx B. Side hip between the iliac crest and anterior iliac spine C. Tissue of the posterior upper arm D. Lower inner thigh 4 finger-widths above the patella

B. Side hip between the iliac crest and anterior iliac spine * The side hip between the iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is preferred for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (e.g. right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape.

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." which of the following responses should the nurse make? A. "Lunch trays should be here within the hour." B. "I am going to listen to your abdomen." C. "I'll get you some water to drink." D. "Lets wait a bit so you don't feel sick."

B. "I am going to listen to your abdomen."

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs."

B. "I will put a night-light in the hallway." * The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home

A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide? A. "The risk of renal toxicity is lessened when a combination of chemotherapy medications is used." B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed." C. "The use of more chemotherapy medications will shorten the time you have to be in treatment." D. "The combination of chemotherapy medications will eliminate the potential for bone marrow suppression."

B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed."

A nurse has administered a medication to a client. Which of the following circumstances should the nurse identify as a medication error that resulted from a performance deficit by the nurse? A. A medication safety coordinator was not present. B. A verbal prescription was transcribed incorrectly. C. A medication with a similar name was dispensed instead of the correct medication. D. An intramuscular injection was given instead of a subcutaneous injection.

D. An intramuscular injection was given instead of a subcutaneous injection. * Performance deficits such as using an improper route of administration for a medication are the most common causes of medication errors that result from human error. The nurse can effectively reduce medication errors in clinical practice by implementing a safety checklist and diligently using the rights of medication administration. If the nurse is not following the rights of medication administration, then the nurse has a performance deficit.

A nurse is caring for a client who has regular occupational exposure to sunlight and presents for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. A raised, circumscribed lesion on the face that contains yellow-white purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

D. An irregularly shaped brown lesion with light blue areas on the neck

A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescent's leg on pillows C. Place an ice pack on the cast D. Assess for manifestations of circulatory impairment

D. Assess for manifestations of circulatory impairment

A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods? A. Cabbage B. Oatmeal C. Milk D. Bananas

D. Bananas

A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with diabetic ketoacidosis? A. Blood glucose 30 mg/dL B. Negative urine ketones C. Blood pH 7.38 D. Bicarbonate level 12 mEq/L

D. Bicarbonate level 12 mEq/L

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery? A. Balanced skeletal traction B. Pelvic belt C. Pelvic sling D. Buck's traction

D. Buck's traction

A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books

D. Chapter books

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

D. Check the client's perineum

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

D. Clean the drain site from the center outward

A charge nurse finds an increased incidence of health-care-associated infections (HAIs) on a long-term care unit. Which priority action should the charge nurse take to address the problem? A. Monitor the staff's hand hygiene techniques B. Hold a mandatory in-service training session about hand hygiene and infection rates C. Require nurses to take an online course on HAIs D. Conduct a chart review to gather data about clients who developed HAIs

D. Conduct a chart review to gather data about clients who developed HAIs