Nursing Practice Fund 313

A nurse is caring for a client who reports an area of rednes, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding a) Obtain a venous duplex ultrasound. b) Apply cold therapy to the affected leg c) Obtain impedance plethysmography d) Monito Homan's sign

A) Obtain a venous duplex ultrasound

A nurse is assessing a client who has fluid overload. What findings should the nurse expect?

Incrased heart rate; Increased blood pressure; Increased respiratory rate

What is the body's first line of defense against bacteria? a) Intact skin b) White blood cells c) Lymph glands d) Inflammatory response

a) Intact Skin

What factors affect drug absorption? Select all that apply a) Route of administration b) Solubility of the drug c) pH and Ionization d) Blood flow to the area e) Protein binding capacity

a) Route of administration b) Solubility of the drug c) pH and Ionization d) Blood flow to the area

A diabetic patient treated with insulin develops low sugar. What type of reaction is this? a) Adverse Reaction b) Idiosyncratic Reaction c) Allergic Reaction d) Toxic Reaction

a0 Adverse Reaction

A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? a) I will remember to inflate the catheter balloon after insertion. b) I can use clean, rather than sterile , technique at home. c) I will dispose of the catheter after use and get a new one each time. d) I will need to replace the catheter weekly.

b) "I can use clean, rather than sterile, technique at home."

A diabetic patient treated with insulin develops low blood sugar. What type of reaction is this? a) Toxic Reaction b) Adverse Reaction c) Allergic Reaction d) Idiosyncratic Reaction

b) Adverse Reaction

The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? a) "Cleanse only those areas likely to cause odor." b) "Provide the patient with warm water for washing his perineum," c) "Wash the patient's back, buttocks, and perineum first." d) "Bathe the patient from head-to-toe, cleanest areas first."

d) "Bathe the patient from head-to-toe, cleanest areas first ."

What is the most significant change in kidney function that occurs with aging? a) Decreased glomerular filtration rate b) Formation of urate crystals c) Proliferation of micro-blood vessels to renal cortex d) Increased renal mass

a) Decreased glomerular filtration rate

The order is for a pain medication to be given prn. Which statement, by the nurse, correctly teaches the client about this medciation order? a) I can give you this medication when you need it, so I will be asking you about your pain level frequently b) This medication will be given to you at a set time every day, probably just before your bath. c) You will be given this medication at bedtime each night so that you can rest d) This meciation may upset your stomach, so always take it with food or mild.

a) "I can give you this medication when you need it, so I will be asking you about your pain level frequently."

An adult patient is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product? a) 18 gauge b) 22 gauge c) 24 gauge d) 26 gauge

a) 18 gauge

The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough? a) With the morning routine laboratory studies b) Approximately 30 minutes before the next dose c) Two hours after the next dose infuses d) While the drug infuses

b) Approximately 30 minutes before the next dose

The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? a) Plan interventions b) Assessment c) Evaluate d) Formulate a nursing diagnosis

b) Assessment

A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? a) Call for assistance to help the patient into the bathtub. b) Wait for the patient to calm down, and then give him a towel bath. c) Allow the patient to go without bathing for a day or two. d) Ask another staff member to attempt the tub bath.

b) Wait for the patient to calm down, and then give him a towel bath.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? a) Dyspnea b) Weak pulse

b) Weak pulse

The physician orders enteric-coated aspirin, 300 mg every day, for the patient with a nasogastric tube. What is the priority action by the nurse? a) Crush the tablet, dissolve it in 30 mL of water, and administer trhough the tube b) Put the tablet in the tube, "milk" it down the tube, and then flush the tube with 60 mL of water. c) Withhold the medication and contact the physician. d) Substitute plain aspirin, dissolve it in 30 mL of water, and administer through the tube.

c) Withhold the medication and contact the physician.

While assessing the costovertebral angle the client experiences pain. What does this finding indicate to the nurse? a) Urinary tract infection b) Renal calculi c) Renal inflammation d) Kidney tumor

c) renal inflammation

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching? a) "I use a suppository every night to have a bowel movement." b) "I carry a water bottle with me because I drinka lot of water." c) "I do wheelchair exercises while watching TV." d) "I only need to catheterize myself twice every day."

d) "I only need to catheterize myself twice a day."

Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? a) 99 F (37.2 C) b) 102 F (38.9 C) c) 103 F (39.4 C) d) 105 F (40.6 C)

d) 105 F (40.6 C)

What type of immunity is provided by intravenous (IV) administration of immunoglobins G? a) Cell-mediated b) Passive c) Humoral d) Active

b) Passive

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? a) Agitation b) Dyspagia c) Nausea d) Hypotension

a) Agitation

Match the correct types of Laxatives: a) Works by adding fiber to the GI tract b) Works on the bowels nervous system c) Works by drawing water into the colon

a) Bulk forming b) Stimulant c) Osmotic laxatives

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? a) Smoking cessation b) Maintenance of ideal weight c) Regular moderate exercise d) Annual influenza immunization

a) Smoking cessation

A patient complains that urine is passed when coughing or sneezing. How should the nurse document this complaint in the patient's healthcare record? a) Stress incontinence b) Urge incontinence c) Overflow incontinence d) Transient incontinence

a) Stress incontinence

Which is an example of an ongoing assessment? a) Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol) b) Examining the patient's mouth at the time she complains of a sore throat c) Requesting the patient to rate intensity on pain scale with the first perception of pain d) Asking the patient in detail how he will return to his normal exercise activities

a) Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol)

A nurse is caring for a client who is taking montelukast. Which of the following outcomes indicates a therapeutic effect of the mediation? a) The client experiences an increased ease of breathing b) The client's platelet count is increased c) The client experiences less muscle pain d) The client's seizure threshold is reduced.

a) The client experiences an increased ease of breathing

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) a) Dysuria b) Tenderness over the symphysis pubis c) Voiding 30m L frequently d) Report of feeling pressure e) Distended bladder

b) Tenderness over the symphysis pubis c) Voiding 30mL frequently d) Report of feeling pressure e) Distended bladder

Which example includes both objective and subjective data? a) The client's blood pressure is 132/68 and her heart rate is 88. b) The client's cholesterol is elevated, and he states he likes fried food. c) the client states she has trouble sleeping and that she drinks coffee in the evening. d) The client states he gets frequent headaches and that he takes aspirin for the pain.

b) The client's cholesterol is elevated, and he states he likes fried food.

The physician prescribes an oral medication for the patient. What is the primary nursing assessment of the patient prior to receiving this medication? a) The patient's understanding of the medication b) The patient's ability to swallow c) The patient's allergies d) The patient's eyesight

b) The patient'sf ability to swallow

Which is an example of self-knowledge if thought or stated by the nurse? a) "I know that I should take the client's apical pulse for 1 minute before giving digoxin." b) "I know that I should follow the client's wishes even though it is not what I would want." c) "I know that I have religious beliefs that may make it difficult to take care of some clients." d) "I know that I need to honor the client's request not to discuss his health concern with the family."

c) "I know that I have religious beliefs that may make it difficult to take care of some clients."

The nurse instructs a woman about providing a clean-catch urine specimen. Which statement indicates that the patient correctly understands the procedure? a) I will need to lie still while you put in a urinary catheter to obtain the specimen. b) I will collect my urine each time I urinate for the next 24 hours. c) I will wipe my genital area from front to back before I collect the specimen midstream. d) I will be sure to urinate into the 'hat' you placed on the toilet seat.

c) "I will wipe my genital area from front to back before I collect the specimen midstream."

While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first? a) Administer epinephrin IM b) Give bolus dose of intravenous fluids c) Stop the infusion of medicaiton d) Prepare for endotracheal intubation

c) Stop the infusion of medication

A client had the cast removed because of a fractured ulna and is directed to perform isometric exercises. Which exercise complies with the healthcare provider's orders? a) Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds and repeat 5 to 10 times. b) Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds and repeat 5 to 10 times. c) Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds and repeat 5 to 10 times. d) Press the right hand against a wall; hold this position for 6 to 8 seconds and repeat 5 to 10 times.

d) Press the right hand against a wall; hold this position for 6 to 8 seconds and repeat 5 to 10 times.

Vitamins and minerals are administered to patients to achieve what effects? a) Subsitutive effects b) Supportive effects c) Palliative effects d) Restorative effects

d) Restorative effects

A client with a high spinal cord injury but well-developed upper body strength is hospitalized for pneumonia. Which transfer device should be used when transferring him from the bed to his wheelchair? a) Mechanical lift b) Transfer belt c) Drawsheet d) Transfer board

d) Transfer board

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratroy values should the nurse monitor for this client due to this medication? a) Potassium b) Cortisol c) Bicarbonate d) Albumin

a) Potassium

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a) Bacteria b) Blood c) Steatorrhea d) Parasites

b) Blood

The nurse plans care for a client who is bedridden. Which laxative should be avoided to treat constipation in this client? a) Osmotic b) Stool softener c) Mineral oil d) Stimulant

c) Mineral oil

Wearing poorly fitting shoes may result in which condition? a) Tinea pedis b) Plantar wart c) Excoriation d) Ingrown toenail

d) Ingrown toenail

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sounds represents which of the following heart conditions? a) Ventricular gallop b) Atrial gallop c) Closure of pulmonic valve d) Closure of the mitral valve

a) Ventricular gallop

Which activity is of the highest priority fro maintaining medical asepsis? a) Washing hands b) Donning gloves c) Applying sterile drapes d) Wearing a gown

a) Washing hands

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client a) White coating in the mouth b) Sedation c) Dry oral mucous membranes d) Increased appetite

a) White coating in the mouth

In which situation would using standard precautions be adequate? Select all that apply a) Emptying a urine collection bag b) Aiding a client to ambulate after surgery c) interviewing a client with a productive cough d) Helping a client perform his own hygiene care e) Inserting a peripheral intravenous catheter

a) emptying a urine collection bag e) Inserting a peripheral intravenous catheter

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? a) The client holds his breath for 10 seconds after inhaling the medication b) The client waits 10 min between inhalations. c) The client takes a quick inhalation while releasing the medication from the inhaler. d) The client exhales as the medication is released is released from the inhaler.

a) the client holds his breath for 10 seconds after inhaling the medication

Which set of vital signs is within normal limits for a client at rest? a) Infant: T 98.8 F (rectal), HR 160, RR 16, BP 120/54 mm Hg b) Adolescent: T 98.2 F (oral), HR 80, RR 18, BP 108/68 mm HG c) Adult: T 99.6 F (oral), HR 48, RR 22, BP 130/84 mm Hg d) Older Adult: T 98.6 F (oral), HR 110, RR 28, BP 170/95 mm Hg

b) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 mm Hg

The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant. Which injection site should the nurse choose to administer this injection? a) Ventrogluteal b) Vastus lateralis c) Deltoid d) Dorsogluteal

b) Vastus laterlis

When measuring a blood pressure, which step is correct? Select all that apply. a) Use a bladder that encircles 40% of the arm b) Wrap the cuff snugly around the client's arm c) Ask the client to hold the arm at heart level d) Have the client sit with feet flat on the floor e) Roll up a sleeve before applying the cuff.

b) Wrap the cuff snugly around the client's arm d) Have the client sit with feet flat on the floor

A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? a) Oatmeal b) Yogurt c) Broccoli d) Pasta

b) Yogurt

The nurse is removing personal protective equipment (PPE). Which item should be removed first? a) Gown b) gloves c) Face sheild d) Hair covering

b) gloves

A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how many 8 ounce servings of fluid to promote healthy bowel function? a) 2-3 b) 9-10 c) 6-8 d) 4-5

c) 6-8

Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? a) Afternoon care b) Early morning care c) Morning care d) Hour of sleep care

d) Hour of sleep care

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? a) Measure the circumference of the thigh b) Palpate the femoral pulse c) Monitor the client's calf for edema d) Instruct the client to wiggle his toes

d) Instruct the client to wiggle his toes

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestatinos should the nurse expect? a) Bradypnea b) Lethargy c) Bradycardia d) Intercostal retractions

d) Intercostal retractions

During a clinic interview, a client states experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? a) Ask the client when in the day dizziness occurs b) Help the client to assume a recumbent position c) Measure both heart rate and blood pressure with the client standing d) Measure vital signs with the client supine, sitting, and standing

d) Measure the vital signs with the client supine, sitting, and standing

In evaluating a client's blood pressure for hypertension, what is the most important action for the nurse to take? a) Use the same type of manometer each time b) Auscultate all five Korotkoff sounds c) Measure the blood pressure in both armsd d) Monitor the blood pressure for a pattern

d) Monitor the blood pressure for a pattern

The nurse administering pain medication every 4 hours is an example which aspect of patient care? a) Assessment data b) Nursing diagnosis c) Patient outcome d) Nursing intervention

d) Nursing intervention

Which area should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply. a) Buccal mucosa b) Around the lips c) Palms d) Tongue e) Nailbeds

a) Buccal mucosa c) Palms d) Tongue

A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow.

1) Inhale deeply and then exhale completely 2) Place her lips firmly around the mouthpiece 3) Breathe in deeply over 2 to 3 seconds while pushing down on the canister 4) Hold her breath for 10 seconds 5) Exhale slowly through the pursed lips 6) Wait 60 seconds between each puff

A nurse is caring for a client who is prescribed warfain therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? a) Prothrombin time (PT) b) Bleeding time c) Hemoglobin (Hgb) d) Activated partial thromboplastin time (aPTT)

a) Prothrombin time (PT)

The nursing instructor ask students how they would assess the fifth vital sign. Which student would be correct? a) "I would have the client rate her pain on a scale of 0 to 10." b) "I would ask the client when she had her last bowel movement." c) "I would interview the client about history of tobacco use." d) "I would weigh the patient."

a) "I would have the client rate her pain on a scale of 0 to 10."

A Client who has been hospitalized for an infection states, "The nursing assistant told me my vitals signs are all within normal limits; that means I'm cured." What would be the nurse's best response? a) "Your vital signs are stable, but there are other things to asses." b) "Your vital signs confirm that your infection is resolved; how do you feel?" c) "We still need to keep monitoring your temperature for a while." d) "I'll let your healthcare provider know so you can be discharged."

a) "Your vital signs are stable, but there are other things to assess.

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? a) 25 mg/dL b) 13 mg/dL c) 10 mg/dL d) 18 mg/dL

a) 25 mg/dL

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? a) A room with air exhaust directly to the outoor environment b) A room in the ICU c) A room with another nonsurgical client d) A room that is within view of the nurses' station

a) A room with air exhaust directly to the outdoor environment

Which urine specific gravity would be expected in a patient admitted with dehydration? a) 1.025 b) 1.010 c) 1.030 d) 1.002

c) 1.030

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the instructions a) A typical course of treatment involves 6 to 9 months of consistent medication use. b) The client's family will also need to take medications to prevent infection. c) Medications will need to be taken until the Mantoux test is negative. d) Medication will need to be taken for the rest of the client's life, even if the client feels better.

a) A typical course of treatment involves 6 to 9 months of consistent medication use.

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? a) Administer a short-acting beta 2-agonist (SABA) b) Determine the cause of the acute exacerbation c) Obtain a peak flow reading d) Administer an inhaled glucocorticoid

a) Administer a short-acting Beta 2-agonist (SABA)

A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medicaton a) Administer the medication 2 hr before exercise b) Give the medication at the onset of wheexing c) Give the medication in the morning daily d) Administer the granules mixed with 20 oz of water

a) Administer the medication 2 hr before exercise.

Anurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? a) Administering a nebulized beta-adrenergic b) Positioning the client in high-Fowler's c) Initiating oxygen thearpy d) Providing immediate rest for the client

a) Administering a nebulized beta-adrenergic

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply) a) An open perineal wound b) Convenience for the nursing staff or the client's family c) Routine acquisition of a urine specimen d) Measurement of residual urine after urination e) Relief of urinary retention

a) An open perineal wound d) Measurement of residual urine after urination e) Relief of urinary retention

A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. Which action must the nurse implement to develop a nursing diagnosis? a) Analyze the assessment data b) Consult standards of care c) Decide which interventions are appropriate d) Ask the client's perceptions of her health problem

a) Analyze the assessment data

A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manisfestation of digoxin toxicity? a) Anorexia b) Ataxia c) Jaundice d) Photosensitivity

a) Anorexia

Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended time. The nurse suspects an interaction with herbal medications. What type of interaction does the nurse suspect?

a) Antagonistic drug interaction

The nurse is teaching a client how to use a portable blood pressure device to monitor blood pressure at home. What is the most important action for the nurse to take? a) Ask the client to demonstrate the use of the blood pressure device b) Explain the importance of frequent calibration of the device. c) Give the client a chart to record his blood pressure readings d) Provide written instructions of the information taught

a) Ask the client to demonstrate the use of the blood pressure device

At the last measurement, the client's vital signs were: oral temperature 98 F (36.7 C) heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs were: oral temperature 103.2 F (38.5 C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention at this time? a) Ask the client whether he has had a warm drink in the last 30 minutes. b) Notify the primary care provider of the client's temperature. c) Ask the client whether he is feeling chilled. d) Take the temperature by a different route

a) Ask the client whether he has had a warm drink in the last 30 minutes.

An older client begins to faint while ambulating in the hallway with the nurse. What action should the nurse take? a) Assist the patient to slide down the leg while being guided to a seated or lying position. b) Grab and hold the patient under the arms and call for assistance. c) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall. d) Instruct the patient to grab the rail in the hallway and call for assistance.

a) Assist the patient to slide down the leg while being guided to a seated or lying position

A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable a) Asthma b) Hypothyroidism c) Osteoarthritis d) Basal cell carcinoma

a) Asthma

The nurse prepares to change a client's bed. Which actions will the nurse take to minimize the effects of the environment during this task? Select all that apply. a) Avoid shaking the linen b) Place pillows on the sink c) Place used linen on the floor d) Hold contaminated linen away from the body e) Fold and place bedspread on the roommate's chair

a) Avoid shaking the linen d) Hold contaminated linen away from the body

Which action represents proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Select all that apply. a) Stand with the body in alignment and maintain erect posture b) Bend at the waist to lift heavy objects from the floor c) Use a wide base of support with your feet at shoulder width d) Keep objects close to your body when carrying them e) Squat to lower the body and use the leg muscles when lifting

a) Bend at the waist to lift heavy objects from the floor c) Use a wide base of support with your feet at shoulder width d) Keep objects close to your body when carrying them e) Squat to lower the body and use the leg muscles when lifting

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which? a) Body secretions turning a red-orange color. b) Constipation c) Balck colored stools d) Staining of teeth

a) Body secretions turning a red-orange color

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. Which action is the most important for the nurse at this time? a) Compare the left pedal pulse with the right pedal pulse b) Count the client's respiratory rate for 1 full minute c) Take the blood pressure in the arm without an IV d) Take an oral temperature with an electronic thermometer

a) Compare the left pedal pulse with the right pedal pulse

A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? a) Consume a diet consisting of bananas, white rice, applesauce, and toast. b) Take loperamide (antidiarrheal) as needed to control diarrhea. c) Increase the consumption of raw fruits and vegetables. d) Drink large quantities of water regularly to prevent deydration.

a) Consume a diet consisting of bananas, white rice, applesauce, and toast.

The nurse assesses a client's vital signs. Which client situation should be reported to the primary care provider? a) Decreased blood pressure after standing up b) Decreased temperature after a period of diaphoresis c) Increased heart rate after walking down the hall d) Increased respiratory rate when the heart rate increases

a) Decreased blood pressure after standing up

The nurse identifies the diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations for a client with an acute respiratory problem resulting from lung disease. Which nursing intervention should be listed first on the care plan? a) Determine airway hourly and as needed b) Administer oxygen as needed c) Monitor arterial blood gas values d) Place the client in a high Fowler's position

a) Determine airway hourly and as needed

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) a) Dyspnea b) Barrel chest c) Clubbing of the fingers

a) Dyspnea b) Barrel chest c) Clubbing of the fingers

Which action protects the body against infection? Select all that apply. a) Eating a healthy, well-balanced diet b) Being an older adult or an infant c) Engaging in leisure activities three times a week d) Exercising for 30 minutes 5 days a week e) Receiving recommended immunizations

a) Eating a healthy, well-balanced diet c) Engaging in leisure activities three times a week d) Exercising 30 minutes 5 days a week e) Receiving recommended immunizations

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the conggestion in my lungs, and I certainly cough a lot, but I can't seem to ... a) Encouraging the client to drink 2 to 3 L of water daily. b) Administering oxygen via nasal cannula at 2 L/min c) Maintaining a semi-Fowler's position as often as possible d) Helping the client select a low-salt diet

a) Encouraging the client to drink 2 to 3 L of water daily

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis? a) Enoxaparin subcutaneous b) Warfarin PO c) Aspirin PO d) Heparin infusion

a) Enoxaparin subcutaneous

A client's radial pulse is full and bounding. Which nursing diagnosis should the nurse select to address this clinical finding? a) Excess Fluid volume b) Deficient fluid volume c) Decreased cardiac output d) Ineffective tissue perfusion

a) Excess fluid volume

A school nurse is assessing a child for pediculosis capitis. Which of the following manifestation should the nurse recognize as an indication of this condition? a) Firmly attached white particles on the hair b) Itching and scratching of the head c) Patchy areas of hair loss d) Thick yellow crusted lesion on a red base

a) Firmly attached white particles on the hair

Which item is best for providing mouth care for an unconscious patient? a) Foam swabs b) Lemon-glycerin swabs c) Hydrogen peroxide d) Cotton-tipped applicator soaked in mouthwash

a) Foam swabs

A client with chronic obstructive pulmonary disease (COPD) receives supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist with this client's breathing? a) Fowler's position b) Sims; position c) Lateral recumbent position d) Lateral position

a) Fowler's position

A nurse in a community clinicis assessing an older adult client for manisfestation of dehydration. Which of the following findings should the nurse expect? a) Furrow in the tongue b) Protruding eyeballs c) Hypothermia d) Elevated blood pressure e) Increased blood pressure f) Decreased heart rate

a) Furrows in the tongue

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? a) Hip arthroplasty b) Myringotomy c) Laparoscopic appendectomy d) Cataract extraction

a) Hip arthroplasty

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? a) Hypercholesterolemia b) Hypetension c) Obesity d) Smoking

a) Hypercholesterolemia b) Hypertension c) Obesity d) Smoking

A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug? a) Hypokalemia b) Hypophosphatemia c) Hypocalcemia d) Hypomagnesemia

a) Hypokalemia

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? a) Hypoxemia b) Dysphagia c) Apnea d) Pleural effusion

a) Hypoxemia

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an ... a) I will be sure to take the albuterol before taking the cromolyn b) I will administer the medicatons 10 minutes apart c) If my breathing begins to feel tight, I will use the cromolyn immediately d) I will use both medications immediately after exercising

a) I will be sure to take the albuterol before taking the cromolyn before taking the cromolyn

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? a) I will take my bronchodilators after meals. b) I will eat five or six small meals each day c) I will rest for at least 30 minutes before eating d) I will choose foods that are not gas-forming

a) I will take my bronchodilators after meals

A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? a) I'll take this medication once a day in the evening b) I'll rinse my mouth after taking this medication c) I'll use a spacer device when I inhale this medication. d) I'll take this medication when I get an asthma attack

a) I'll take this medication once a day in the evening.

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apenic episodes. Which of teh following client statements indicates an understanding of ... a) If I could lose about 50 pounds, I might stop having so many apneic episodes b) I'll sleep better if I take a sleeping pill at night. c) I'll get a humidifier to run at my bedside at night. d) It might help if I tried sleeping only on my back

a) If I could lose about 50 pounds, I might stop having so many apneic episodes.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physio a) Increased calcium excretion b) Decreased RBC production c) Increased insulin production d) Decreased sodium excretion

a) Increased calcium excretion

A nurse is assessing a client who has a fracture of the femur. the nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse a) Increased respiratory rate from 18 to 44/min b) Increased blood pressure from 112/68 to 120/72 mm Hg c) Increased heart rate from 68 to 72/min d) Increased oral temperature from 36.6 C (97.8 F) to 37 C (98.6 F)

a) Increased respiratory rate from 18 to 44/min

Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer? a) Keep the nasogastric tube to low suction. b) Administer morphine 4 mg IV every 2 hours for pain. c) Insert an indwelling urinary catheter to monitor I&O. d) Administer IV fluids at 125 mL/hr

a) Keep the nasogastric tube to low suction.

The patient is receiving a sustained-release capsule for his cardiac condition. The patient tells the nurse there is no way he can swallow such a large pill. What is the best response by the nurse? a) Let me contact your physician to see if a change can be made. b) Place the capsule on the back of your tongue, and drink a full glass of water. c) I will open the capsule and sprinkle the contents over some applesauce for you to eat. d) It may be difficult, but try to swallow the capsule as it is the best medicine for your heart condition

a) Let me contact your physician to see if a change can be made.

An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which is the correct description of osteoporosis? a) Loss of bone density that increases the risk of fracture b) Degenerative joint disease that produces pain and decreased function c) Chronic inflammatory joint disease that must be treated with steroids d) Acute infection in the bone that must be treated with antibiotics

a) Loss of bone density that increases the risk of fracture

Which is an appropriate goal for a patient with urinary incontinence? Select all that apply. a) Maintain daily oral fluids to 8 to 10 servings per day. b) Increase the intake of citrus fruits. c) Engage in high-impact, aerobic exercise. d) Limit daily caffeine intake to less 100mg e Lose weight if BMI is greater than 30.

a) Maintain daily oral fluids to 8 to 10 servings per day. d) Limit daily caffeine intake to less than 100 mg. e) Lose weight if BMI is greater than 30.

A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base? a) Metabolic alkalosis b) Metabolic acidosis c) Respiratroy acidosis d) Respiratory alkalosis

a) Metabolic alkalosis

A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing? a) Mild adverse reaction b) Dose-related adverse reaction c) Toxic reaction d) Anaphylactic reaction

a) Mild adverse reaction

Which action should the nurse take when beginning bladder training using scheduled voiding? a) Offer the patient a bedpan every 2 hours while she is awake. b) Increase the frequency between voiding even if urine leakage occurs. c) Increase the voiding interval by 30 to 60 minutes each week. d) Frequently ask the patient whether she has the urge to void.

a) Offer the patient a bedpan every 2 hours while she is awake.

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take? a) Perform the Helmlich maneuver b) Assist the client to the floor and begin mouth-to-mouth resuscitation. c) Slap the client on the back several times d) Observe the client before taking further action.

a) Perform the Helmlich maneuver

A nurse is admitting a child who has suspected epiglottis. Which of the following actions should the nurse take first? a) Place the child on droplet precautions. b) Assist with obtaining an x-ray of the child'e neck c) Initiate IV antibiotics d) Administer 0.9 % sodium chloride IV solution

a) Place the child on droplet precautions.

Which action should the nurse take when preparing a patient for a bed bath? a) Place the nurse call device within reach for safety b) Cover the patient with the top linens from the bed c) Have the patient completely bathe himself d) Wash the patient's body without assistance from the patient for safety

a) Place the nurse call device within reach for safety b) Cover the patient with the top linens

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medication a) Prednisone b) Theophyline c) Montelukast d) Propranolol

a) Propranolol

Which task can the nurse safely safely delegate to the nursing assistive personnel? a) Providing indwelling urinary catheter care b) Administering a continuous bladder irrigation c) Palpating the bladder of a patient who is unable to void. d) Obtaining the patient's history and physical assessment

a) Providing indwelling urinary catheter care

The nurse must administer eardrops to an infant. How should this mediation be given? a) Pull the pinna down and back before instilling the drops b) Pull the pinna upward adn outward before instilling the drops c) Instill the drops directly; no special positioning is necessary d) Position the patient supine with the head of the bed elevated 30

a) Pull the pinna down and back before instilling the drops

What would be the most appropriate goal for a frail, older patient with a nursing diagnosis of Risk for Injury after hip surgery? a) Remain free from injury or falls throughout hospital stay b) Increase activity tolerance by discharge from hospital c) Demonstrate effective breathing when ambulating d) Increase mobility by discharge from hospital

a) Remain free from injury or falls throughout hospital stay

Which characteristic do the various definitions of critical thinking have in common? a) Requires reasoned thought b) Asks the questions "why?" or "how?" c) Is a hierarchical process d) Demands specialized thinking skills

a) Requires reasoned thought

A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority? a) Respiratory rate b) Burns of the mouth c) Visual acuity d) Bowel sounds

a) Respiratory rate

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide? a) Rinse the mouth after administration b) Take the medication with meals c) Limit caffeine intake d) Check the pulse after medication administration

a) Rinse the mouth after administration.

Match with the correct response: a) Name an osmotic laxative b) Name a stimulant laxative c) Name a bulk laxative

a) Senna b) Miralax c) Name a bulk laxative

The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? a) Skeletal b) Smooth c) Cardiac d) Slow-twitch fibers

a) Skeletal

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a) Urinary tract infection b) Urinary incontinence c) Urinary incontinence d) Urinary frequency

a) Urinary tract infection

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? a) Urine output of 175 mL in the past 8 hr b) Urine is cloudy after sitting in the urinal for 6 hr c) Urine output of 2,200 mL in the past 24 hr d) First-voided urine in the morning has a strong odor.

a) Urine output of 175 mL in the past 8 hr

The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? a) Use an electric razor for shaving b) Apply skin moisturizer c) Use less soap when bathing d) Floss teeth daily

a) Use an electric razor for shaving

The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. Which NAP action indicates that teaching has been effective? Select all that apply. a) Uses a paper towel to turn off the faucet. b) Holds fingertips above the wrists while rinsing off the soap. c) Removes all rings and watch before washing hands d) Cleans underneath each fingernail e) Rubs hands vigorously for 15 seconds

a) Uses a paper towel to turn off the faucet c) Removes all rings and watch before washing hands d) Cleans underneath each fingernail e) Rubs hands vigorously for 15 seconds

A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply? a) "You don't need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture." b) "Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain." c) "We will need to get a venous Doppler study to make sure that there is not a fracture." d) "First, we need to get an MRI to diagnose your injury as a fracture instead of strain or sprain."

b) "Sprains, strains, or fracture have similar symptoms at first; you will need an x-ray of the joint to be certain."

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? ( Select all that apply.) a) " You might require an anterior vaginal repair." b) "You should limit fluids in the evening." c) "You might require intermittent urinary catheterization." d) "You should restrict your intake of caffeine." e) "Your provider might prescribe anticholinergic medications."

b) "You should limit fluids in the evening." d) "You should restrict your intake of caffeine." e) "Your provider might prescribe anticholinergic medications."

A patient is admitted to the hospital with tuberculosis. Which precaution must the nurse institute when caring for this patient? a) Droplet b) Airborne c) Direct Contact d) Indirect Contact

b) Airborne

The nurse uses the nursing process prior to administering any medications. Which step will ensure the best patient safety? a) Assess the patient's development level. b) Assess the patient's medical history, including allergies. c) Assess the patient's disease process. d) Assess the patient's learning needs.

b) Assess the patient's medical history, including allergies.

A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? a) Feeding Self-care Deficit b) Bathing Self-care Deficit c) Dressing Self-care deficit d) Activity Intolerance

b) Bathing Self-care Deficit

A nurse is assessing a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which .... a) Brudzinski's sign b) Chvostek's sign c) Babinski's sign

b) Chvostek's sign

Which type of isolation would you expect a patient with frequent diarrhea to be in? a) Airborne b) Contact c) Droplet d) Protective

b) Contact

Which information in a client's health might indicate a risk for primary hypertension? a) Consumes a high-protein diet b) Drinks three or four beers every day c) Has a family history of kidney disease d) Does not engage in physical exercise

b) Drinks three or four beers every day

Which nursing intervention is considered an independent intervention? a) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour b) Encouraging the postoperative client to perform coughing and deep breathing exercises c) Explaining his diet to the client; then communicating the teaching with the dietitian d) Administering morphine sulfate 2 mg IV to the client with postoperative pain

b) Encouraging the postoperative client to perform coughing and deep breathing exercises

A nurse is caring for an older client who had a femoral head fracture 24 ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client ... a) Airway obstruction b) Fat embolism c) Pneumothorax d) Pneumonia

b) Fat embolism

An older patient is unsteady when walking about the room and reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping this patient ambulate? a) Crutches b) Gait/Transfer belt c) Cane d) Walker

b) Gait/Transfer belt

Which factor places the patient at risk for constipation? Select all that apply. a) Lactose intolerance b) High-dose calcium therapy c) High intake of caffeine d) Consuming spicy foods e) sedentary lifestyle

b) High-dose calcium therapy e) Sedentary lifestyle

A patient on strict bedrest for 5 days has not had a bowel movement although normally this occurs every day. When determining the nursing diagnosis what would be causing this patient's constipation? a) Change in previous pattern b) Immobility c) Dietary intake d) Change in environment

b) Immobility

Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen? a) After an explanation and written materials, describes the expected actions and adverse reactions of his medication b) In 1 week after instructional session, describes the expected actions and adverse reactions of his medications c) Follows the treatment plan as prescribed d) Experiences no adverse effect from his prescribed treatment plan

b) In 1 week after instructional session, describes the expected actions and adverse reactions of his medication

What should the nurse consider for a patient who has a temperature of 101F (38.3 C)? a) Warm blankets b) Increased fluids c) Bedrest d) Tepid bath

b) Increased fluids

A nurse is planning care for a client who cystitis. Which of the following interventions should the nurse include in the plan? a) Instruct the client to drink 1L of fluid each day. b) Instruct the client to avoid drinking carbonated beverages. c) Instruct the client to take antibiotics until dysuria is no longer present. d) Instruct the client to drink 240 mL of tomato juice each day

b) Instruct the client to avoid drinking carbonated beverages.

Which statement about the nursing process is correct? a) It was developed from the ANA Standards of Care. b) It is a problem-solving method to guide nursing activities. c) It is a linear process with separate, distinct steps d) It involves care that only the nurse will give.

b) It is a problem-solving method to guide nursing activities.

The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. The nurse ensured the nursing assistive personnel changed the patient's position every 2 hours. In the evaluation phase of the nursing process, which would the nurse do first? a) Determine whether she has gathered enough assessment data b) Judge whether the interventions achieved the stated outcomes c) Follow up to verify that care for the nursing diagnosis was given d) Decide whether the nursing diagnosis was accurate for the patient's condition.

b) Judge whether the interventions achieved the stated outcomes.

The physician has ordered several medications for the patient. What does the nurse recognize as responsibilities regarding administration of medications? Select all that apply. a) Knowing the cost of the medication b) Knowing the reason the medication was prescribed for this patient c) Knowing how the medicaiton is to be administered d) Knowing how the medication is supplied by the pharmacy e) Knowing the name of the medicaiton

b) Knowing the reasong the medicaiton was prescribed for this patient. c) Knowing how the medication is to be administered d) Knowing how the medication is supplied by the pharmacy e) Knowing the name of the medicaiton

Which medication class will the primary care provider most likely prescribe to increase urine output in the patient with congestive heart failure? a) MAO inhibitor b) Loop diuretic c) Anticholinergic d) Thiazide diuretic

b) Loop diuretic

A few nurses on a unit have proposed to the nurse manage that the process for documenting care on the unit be changed. They have described a completely new system. The nurse should have a critical attitude because it helps the manage to do which item? a) Consider all the possible advantages and disadvantages b) Maintain an open mind about the proposed change c) Apply the nursing process to the situation d) Make a decision based on past experience with documentation

b) Maintain an open mind about the proposed change

A nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following ? a) Respiratory acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Metabolic acidosis

b) Metabolic alkalosis

Which body system must interact to produce mobility and locomotion? Select all that apply. a) Digestive system b) Muscles c) Skeleton d) Nervous system e) Blood

b) Muscles c) Skeleton d) Nervous system

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication? a) Constipation b) Paralytic ileus c) Small bowel obstruction d) Diarrhea

b) Paralytic ileus

Which course of action taken by a patient with osteoporosis indicates that teaching about the health problem was effective? a) Taking a calcium supplement every day and increasing phosphorous intake b) Participating in an aerobic barbell strength class at the gym three times a week c) Using a wheelchair to reduce the risk of spontaneous fractures to legs and feet d) Seeking healthcare by scheduling a follow-up examination with bone density testing

b) Participating in an aerobic barbell strength class at the gym three times a week

The primary care provider prescribes nitrglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug? a) Place the drug in the cheek and allow it to dissolve b) Place the drug under the tongue and allow it to dissolve c) Inject the drug superficially into the subcutaneous tissue d) Give the pill and water to the patient for him to swallow the tablet

b) Place the drug under the tongue and allow it to dissolve

A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care? a) Instruct the client to avoid movement of the affected leg b) Prevent the hip flexion of the affected extremity c) Position the lower extremities so that they are touching d) Ensure that the client's heels are touching the bed.

b) Prevent the hip flexion of the affected extremity

A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? a) Contact b) Protective or reverse c) Droplet d) Airborne

b) Protective or reverse

Which client would probably have a higher than normal respiratory rate? a) Recovering from surgery and receiving a narcotic analgesic b) Recovering from surgery and lost a unit of blood intraoperatively c) Lived at a high altitude and then moved to sea level d) Exposed to the cold and is now hypothermic

b) Recovering from surgery and lost a unit of blood intraoperatively

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? a) Have the client take several deep breaths b) Request the client take a deep breath and cough c) Take the client's blood pressure and apical pulse d) Count the client's respiratory rate for 1 minute

b) Request the client take a deep breath and cough

Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range? a) Oral temperature 100 F (37.8 C) b) Respiratory rate 26 breaths/min and shallow c) Apical heart rate 56 beats/min d) Blood pressure 124/82 mm Hg

b) Respiratory rate 26 breaths/min and shallow

A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate? a) Risk for Infection b) Risk for Impaired Skin Integrity c) Risk for Deficient Fluid Volume d) Impaired Skin Integrity

b) Risk for Impaired Skin Integrity

Which patient is at risk for decreased activity? Select all that apply. a) Older adult who walks at the mall for physical activity b) Someone living in a skilled nursing facility c) Healthy adult who works as a computer programmer d) Obese child who enjoys video games e) Healthy adult with a spinal cord deformity who walks with a cane

b) Someone living in a skilled nursing facility c) Healthy adult who works as a computer programmer d) Obese child who enjoys video games

When caring for a patient with osteoporosis, which is the most important action to take to minimize progression of the disease? a) Take a calcium supplement twice a day b) Start a weight-bearing exercise program c) Avoid strenuous activity that puts stress on the bones. d) Schedule regular healthcare checkups

b) Start a weight-bearing exercise program

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply. a) Rhythm of the pulses b) Strength of the pulses c) Bilateral equality of pulses d) Rate compared with apical pulse e) Location of the pulse

b) Strength of the pulses c) Bilateral equality of pulses

A patient with diarrhea is incontinent of liquid stool. The nurse documents that the patient has excoriated skin on the buttocks. Which finding by the nurse led to this documentation? a) Skin was softened from prolonged exposure to moisture. b) Superficial layers of skin were absent. c) The epidermal layer of skin was rubbed away. d) A lesion caused by tissue compression was present.

b) Superficial layers of skin were absent. c) The epidermal layer of skin was rubbed away.

A patient who has been immobile since sustaining injuries in a motor vehicle crash complains of constipation. The nurse encourages him to consume eight to ten 8 ounce servings of fluid daily. Which fluid should the patient avoid because of the diuretic effect? Select all that apply. a) Water b) Tea c) Coffee d) Ginger Ale e) Cranberry Juice

b) Tea c) Coffee

The nurse prepares a teaching tool about normal urination for a group of community members. What should the nurse include in this teaching? Select all that apply. a) Stretch receptors in the bladder cause the detrusor muscle to relax b) The internal sphincter keeps urine from entering the urethra. c) Stretch receptors in the bladder are activated when 200 to 450 mL of urine is present d) Stretch receptors in the bladder cause the internal sphincter to contrict e) Voiding can be voluntarily delayed.

b) The internal sphincter keeps urine from entering the urethra c) Stretch receptors in the bladder are activated when 200 to 450 mL of urine is present. e) Voiding can be voluntarily delayed.

The nurse is providing medication education to a client with hypertension. The nurse teaches the client that the physician ordered a diuretic to decrease the amount of fluid in the client's body. Which statement best describes the nurse's instruction? a) The nurse did not provide appropriate medication education. b) The nurse explained the drug's mechanish of action c) The nurse taught the client about a prototype drug. d) The nurse explained the consequences of not using the drug

b) The nurse explained the drug's mechanism of action.

A client's vital signs at the beginning of the shift are oral temperature 99.3 F (37 C), heart rate 82, respiratory rate 14, and blood pressure 118/76 mm Hg. Four hours later the client's oral temperature is 102.2 F (39 C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats per minute? a) 62 b) 82 c) 102 d) 122

c) 102

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? a) 32-year-old admitted with a closed head injury b) 76-year-old admitted with septic shock c) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago d) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

c) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago

For which patient problem is it most important to provide frequent perineal care? a) Recovering from diabetic ketoacidosis b) Has a circumcised penis c) Active lower gastrointestinal bleeding d) History of acute asthma

c) Active lower gastrointestinal bleeding

A patient's digoxin level is 1.2 ng/mL; the therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse take? a) Notify the prescriber to reduce the dose b) Withhold the next dose of digoxin. c) Administer the next dose as prescribed. d) Notify the prescribing healthcare provider to increase the dose.

c) Administer the next dose as prescribed.

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? a) Bacteria b) Diuretics c) Aging d) Obesity e) Smoking

c) Aging d) Obesity e) Smoking

The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance? a) Crush time-release capsules to put in his favorite food. b) Give medication quickly before he knows what is happening c) Allow the child to eat a frozen pop before receiving the medication. d) Mask the flavor of medication in a toddler cup with orange juice.

c) Allow the child to eat a frozen pop before receiving the medication.

Which is a key treatment intervention for the patient admitted with diverticulitis? a) Antacid b) Antidiarrheal agent c) Antibiotic therapy d) NSAIDs

c) Antibiotic therapy

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? a) Within the expected range b) Venous insufficiency c) Arterial insufficiency d) Thrombus formation in the vein

c) Arterial insufficiency

A nurse in a clinic is interviewing a patient who will undergo diagnostic testing. The nurse should ask about a patient's potential who allergies during which phase of the nursing process? a) Planning b) Evaluation c) Assessment d) Implementation

c) Assessment

What action is most important in limiting the nurse's risk of back injuries? a) Use good body mechanics at all times b) Work with another nurse or an aide when lifting and turning patients c) Avoid manual lifting by using assistive devices as often as possible d) Develop a lift team at the clinical site

c) Avoid manual lifting by using assistive devices as often as possible

When caring for a client with a fever, what should the nurse expect to be increased? a) Urine output b) Sensitivity to pain c) Blood pressure d) Respiratory rate

c) Blood pressure

In order to achieve balance, body mass must be distributed around which point? a) Center of body alignment b) Center of balance c) Center of gravity d) Base of support

c) Center of gravity

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? a) Encourage coughing and deep breathing b) Encourage regular use of the incentive spirometer c) Encourage the client to increase fluid intake d) Entrouage the client to ambulate frequently

c) Encourage the client to increase fluid intake

Which food item should the nurse instruct the patient to consume to prevent or treat constipation? a) Milk and cheese b) Bread and pasta c) Fruits and vegetables d) Lean meats

c) Fruits and vegetables

What is the most frequent cause of the spread of infection among institutionalized patient's? a) Airborne microbes from other patients b) Contact with contaminated equipment c) Hands of healthcare workers d) Exposure from family members

c) Hands of healthcare workers

Which is true of synarthroses joints? a) Freely movable b) Capable of only limited movement c) Immovable d) Painful with movement

c) Immovable

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? a) Phagocytosis b) Complement cascade c) Inflammation d) Immunity

c) Inflammation

A nurse is assessing a 74-year old male patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P= 72, RR= 16, BP=132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, "I have to stop. I can't do this anymore." The nurse measures his vital signs again: P=152, RR=40, BP=172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? a) Anxiety b) Orthostatic hypotension c) Limited activity tolerance d) Respiratory distress

c) Limited activity tolerance

The nurse prepares to remove the artificial eye of a patient sitting at the bedside. In which position should the patient be placed to facilitate the removal of this device? Ask the patient to: a) Lean forward and rest the arms on the overbed table. b) Sit back in the chair and tilt the head back. c) Move to the bed and lie down. d) Stand up and lean over the bed

c) Move to the bed and lie down

A patient recovering from a bowel resection a few hours ago has a urine output of 50 mL/2 hr. Which action should the nurse take? a) Do nothing; this is normal postoperative urine output. b) Administer the patient's routine diuretic dose early c) Notify the provider about the patient's oliguria d) Increase the infusion rate of the patient's IV fluids

c) Notify the provider about the patient's oliguria.

Which is the most important reason for nurses to be critical thinkers? a) Nurses need to follow policies and procedures b) Nurses work with other healthcare team members c) Nurses care for clients who have multiple health problems d) Nurses have to be flexible and work variable schedules

c) Nurses care for clients who have multiple health problems

During an assessment of a newly admitted client the nurse measure blood pressure, abdominal circumference, and pulse rate. Which critical thinking skill is the nurse using? a) Recognizing gaps in one's own knowledge b) Recognizing the need for more information c) Objectively gathering information on a problem or issue d) Evaluating the credibility and usefulness of sources of information

c) Objectively gathering information on a problem or issue

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? a) Position head of bed at 10 degrees b) Encourage fluid intake of 1500 mL/day c) Obtain a sputum culture d) Cough and deep breathe every 8 hr

c) Obtain a sputum culture

What term is used to describe the time it takes for drug concentration to reach a therapeutic level in the blood? a) Peak action b) Duration of action c) Onset of action d) Half-life

c) Onset of action

The nurse is caring for a 25-year old male quadriplegic patient. Which treatment should the nurse perform to decrease the risk of joint contracture and promote joint mobility? a) Active ROM b) Turning the patient every 2 hours c) Passive ROM d) Administering glucosamine supplements

c) Passive ROM

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? a) Medicate the client for pain b) Instruct the client on use of crutches. c) Perform neurovascular checks of the extremities. d) Direct the client to perform exercises of the ankle and toes.

c) Perform neurovascular checks of the extremities.

The nurse instructs a client scheduled for surgery on deep breathing and coughing exercises even though the client no history of respiratory problems. Which type of nursing intervention did the nurse perform? a) Health promotion b) Treatment c) Prevention d) Assessment

c) Prevention

The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? a) Avoid bathing the patient. b) Use cool water for bathing c) Provide care in small intervals d) Rub briskly when towel drying

c) Provide care in small intervals

A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis? a) Cystits b) Enuresis c) Renal Failure d) Renal Calculi

c) Renal Failure

What is the correct method for turning an adult patient who recently sustained a spinal cord injury? a) Ask the patient to assist with the turn by holing the siderails of the bed b) Place a drawsheet under the patient to assist with turning c) Request help from another nurse to perform the logrolling technique d) Use a mechanical lift for safe turning and protecting the nurse's back

c) Request help from another nurse to perform the logrolling technique

The nurse identifies the diagnosis Impaired Urinary Elimination in an older adult patient admitted after a stroke. Impaired Urinary Elimination places the patient at risk for which complication a) Bowel Incontinence b) Renal calculi c) Skin breakdown d) Urinary tract infection

c) Skin breakdown

The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which patient behavior indicates teaching has bee effective? a) Reduces intake of gluten-containing products. b) Consumes only two servings of caffeinated beverages per day. c) Takes measures to reduce stress level. d) Does not consume foods that contain lactose.

c) Takes measures to reduce stress level.

A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug? a) Abuse b) Misuse c) Tolerance d) Dependence

c) Tolerance

What is the best intervention to protect the integument of a frail, malnourished, immobile patient? a) Offering the patient six small meals a day b) Assisting the patient to sit in a chair three times a day c) Turning the patient at least every 2 hours d)Administering fluid boluses as directed by the healthcare provider

c) Turning the patient at least every 2 hours

A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? a) Request that the prescriber change the order to the IV route. b) Administer the medication by the IM route. c) Use a needleless syringe to place the medication in the side of the mouth. d) Add the dose to a small amount of food or beverage to facilitate swallowing

c) Use a needleless syringe to place the medication in the side of the mouth.

Which nursing behavior indicates the highest potential for spreading infections among clients? a) Disinfects dirty hands with antibacterial soap b) Allows alcohol-based rub to dry for 10 seconds c) Washes hands only when leaving each room d) Uses cold water for medical asepsis

c) Washes hands only when leaving each room

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following clients statements indicates a need for further teaching? a) "I will need to empty my bladder regularly and completely". b) "I will need to drink apple cider vinegar each day". c) "I need to drink 8 cups of liquid each day". d) "I will need to wipe my perineal area from back to front after urination."

d) "I will need to wipe my perineal area from back to front after urination."

Which differentiates a nursing diagnosis from a medical diagnosis? a) Terminology for the client's disease or injury b) A part of the client's medical diagnosis c) The client's presenting signs and symptoms d) A client's response to a health problem

d) A client's response to a health problem

A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions? a) Adduction b) External rotation c) Internal rotation d) Abduction

d) Abduction

A frail older client is expected to ambulate with a walker after surgery to repair a fractured left hip. What action should the nurse take to support the client's use of the walker? a) Aerobic exercise with deep breathing b) Quadriceps and gluteal repetitions c) Isometirc toning of lower legs d) Arm resistance training

d) Arm resistance training

What is the best plan as the nurse prepares to administer a topical medciation ? a) Check the medication for interactions with other medications. b) Take the patient's vital signs c) Educate the patient to not disturb the patch. d) Assess the patient's skin where the medication will be applied.

d) Assess the patient's skin where the medication will be applied.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs . The nurse should ... a) An upper respiratory infection b) Delayed gastric emptying c) Pulmonary edema d) Atelectasis

d) Atelectasis

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? a) Irrigate the catheter once each shift. b) Clean the perineal area with an antiseptic solution daily. c) Replace the catheter every 3 days. d) Check the catheter tubing for kinks or twisting.

d) Check the catheter tubing for kinks or twisting.

A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? a) Stop taking the drug immediately if diarrhea develops. b) Take an antidiarrheal agent, such as diphenoxylate. c) Increase your intake of fiber until the diarrhea stops. d) Consume yogurt while taking the antibiotic.

d) Consume yogurt daily while taking the antibiotic.

When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry stool. What should the nurse do? a) Apply a skin barrier cream to the buttocks to prevent irritation. b) Give the baby sterile water until the mother's milk comes in. c) Notify the provider immediately. d) Do nothing; this is normal.

d) Do nothing; this is normal

When should the nurse make systematic observations about a patient? a) When the patient has specific complaints b) With the first assessment of the shift c) Each time the nurse gives medication to the patient d) Each time the nurse interacts with the patient

d) Each time the nurse interacts with the patient

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? a) Cleanse the perinuem from back to front. b) Offer the client the bedpan every 2 hr. c) Obtain a prescription for an indwelling urinary catheter. d) Encourage fluid intake at and between meals.

d) Encourage fluid intake at and between meals.

Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injectin into the site? a) Apply a warm compress b) Massage the site in a circular motion c) Apply a soothing lotion d) Have the client assume a sitting position

d) Have the client assume a sitting position

Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site? a) Apply a warm compress b) Massage the site in a circular motion c) Apply a soothing lotion d) Have the client assume a sitting position

d) Have the client assume a sitting position

For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? a) Recovering from abdominal surgery 2 hours ago b) Experienced a fractured hip yesterday c) Dehydrated from vomiting d) History of heart and lung disease

d) History of heart and lung disease

The nurse auscultates low-pitched infrequent bowel sounds in a patient recovering from a bowel resection. How should this finding be documented? a) Normal bowel sounds b) Abdominal bruit sounds c) Hyperactive bowel sounds d) Hypoactive bowel sounds

d) Hypoactive bowel sounds

A nurse is assessing a client who has developed atelectasis potoperatively. Which of the following findings should the nurse expect? a) Friction rub b) Facial flushing c) Decreasing respiratory rate d) Increasing dyspnea

d) Increasing dyspnea

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? a) When fingers feel sticky b) After 5 to 10 seconds c) When leaving the client's room d) Once fingers and hands feel dry

d) Once fingers and hands feel dry

A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? a) Supportive b) Restorative c) Substitutive d) Palliative

d) Palliative

Which nursing diagnosis is the most appropriate to ensure the safety of a frail older client with a history of emphysema recovering from hip replacement surgery? a) Impaired Physical Mobility related to weakness b) Ineffective Breathing Pattern related to disease process c) Activity Intolerance related to injury d) Risk for Injury related to medical condition

d) Risk for Injury related to medical condition

The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if the patient is placed in which position? a) Supine b) Prone c) Semi-Fowler's d) Side-Lying

d) Side-Lying

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? a) The client who has been NPO since midnight for endoscopy. b) The client who has end-stage renal failure and is scheduled for dialysis today. c) The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. d) The client who has gastroenteritis and is febrile.

d) The client who has gastroenteritis and is febrile.

The student nurse asks for an indwelling urinary catheter for a hospitalized patient who is incontinent. Which response should the nurse make about the use of catheters only being absolutely necessary? a) They are too expensive for routine use. b) They contain latex, increasing the risk for allergies. c) Insertion is painful for most patients. d) They are the leading cause of infection.

d) They are the leading cause of infection.

A nurse is providing discharge teaching about clean intermittent self-catherization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? a) Perform catheterization when you recognize the urge to void. b) Inflate the balloon when the urine flow stops. c) Hold the penis at a 30 to 45 angle when inserting the catheter. d) Use soap and water to wash the catheter after each use.

d) Use soap and water to wash the catheter after each use.

The nurse is instructing a patient about performing home testing for fecal occult blood. What food should the patient state to avoid eating for 3 days before the test? a) Eggs b) Oatmeal c) Milk d) Beef

d) beef