Physiological Integrity
The client is prescribed sotalol 80mg orally twice daily. Which assessment finding indicates that the client is experiencing an adverse effect of the medication? 1. Dry mouth 2. Palpitations 3. Diaphoresis 4. Difficulty swallowing
2
The clinic nurse prepares to assess a client who is in the second trimester of pregnancy. When measuring the fundal height, what should the nurse expect to note with this measurement regarding gestational age? 1. It is less than gestational age. 2. It correlates with gestational age. 3. It is greater than gestational age. 4. It has no correlation with gestational age.
2
The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory condition is improving? 1. Edema of the hands and feet 2. Urine output of 3mL/kg/hour 3. Presence of a systolic murmur 4. Respiratory rate between 60 and 70 breathes per minute
2
The nurse notes an isolated premature premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take? 1. Prepare for defibrillation. 2. Continue to monitor the rhythm. 3. Prepare to administer lidocaine hydrochloride. 4. Notify the primary health care provider immediately.
2
To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food? 1. Bowel sounds 2. Chewing ability 3. Current appetite 4. Food preferences
2
Which action should the nurse take before performing a venipuncture to initiate continuous intravenous (IV) therapy? 1. Apply a cool compress to the affected area. 2. Inspect the IV solution and expiration date. 3. Secure a padded arm board above the IV site. 4. Apply a tourniquet below the venipuncture site.
2
The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects should the nurse teach the client to expect regarding this type of therapy? Select all that apply. 1. Increased heart rate 2. Improved well-being 3. Lowered blood pressure 4. Increased respiratory rate 5. Decreased muscle tension 6. Increased neural impulses to the brain
2, 3, 5
The nurse is monitoring a client who was recently prescribed total parental nutrition (TPN). Which action should the nurse take when obtaining a finger-stick glucose reading of 425mg/dL (24.48mmol/L)? 1. Stop the TPN. 2. Administer insulin. 3. Notify the primary health care provider. 4. Decrease the flow rate of the TPN.
3
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding? 1. Loud wheezing 2. Wheezing on expiration 3. Noticeably diminished breath sounds 4. Increased displays of emotional apprehension
3
The nurse is reviewing the laboratory results for a client who is receiving torsemide 5mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication? 1. A chloride level of 98mEq/L (98mmol/L) 2. A sodium level of 135mEq/L (135mmol/L) 3. A potassium level of 3.1mEq/L (3.1mmol/L) 4. A blood urea nitrogen (BUN) level of 15mg/dL (5.4mmol/L)
3
An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client's neuromuscular status? Select all that apply. 1. Pain level 2. Urinary output 3. Ability to move all extremities 4. Capillary refill in all extremities 5. Ability to flex and extend the feet 6. Ability to detect sensations in all extremities
3, 4, 5, 6
The home care nurse is making a follow-up visit to a client after receiving a renal transplant. Which assessment data support the possible existence of acute graft rejection? Select all that apply. 1. Pale skin color 2. Urine output of 45mL/hour 3. Blood pressure of 164/98mmHg 4. Temperature of 102.4F (39.1C) 5. Client reporting "feeling so very tired" 6. Client reporting that graft site is tender when touched
3, 4, 5, 6
A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure? 1. Ensure that the client is appropriately dressed. 2. Administer an opioid analgesic 30 to 60 minutes before therapy. 3. Schedule the therapy at a time when the client generally takes a nap. 4. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
2
An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking? 1. Left leg discomfort 2. Weak biceps brachii 3. Triceps muscle spasms 4. Forearm muscle weakness
4
The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if which is noted? 1. Breast engorgement 2. Elevated white blood cell count 3. Lochia rubra on the second day postpartum 4. Fever over 38C (100.4F) beginning 2 days postpartum
4
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection? 1. Dependent edema 2. Diminished distal pulse 3. Coolness and pallor of the skin 4. Presence of warm areas on the cast
4
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain? 1. Supine with knees slightly raised 2. High Fowler's position with the foot of the bed flat 3. Semi-Fowler's position with the foot of the bed flat 4. Semi-Fowler's position with the knees slightly raised
4
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety? 1. Monitoring for heel breakdown 2. Monitoring for bladder distention 3. Monitoring for extremity shortening 4. Monitoring for blanching ability of toe nail beds
4
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication? 1. Hypotension 2. Photophobia 3. Profuse sweating 4. Decrease in urine output
4
The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately? 1. Document the findings. 2. Prepare for immediate birth. 3. Increase the rate of oxytocin infusion. 4. Administer oxygen to the client via face mask.
4
Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction? 1. pH 7.25, PaCO2 55, HCO3 24 2. pH 7.30, PaCO2 38, HCO3 20 3. pH 7.48, PaCO2 30, HCO3 23 4. pH 7.49, PaCO2 38, HCO3 30
4
Which nursing assessment question should be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period? 1. "Have you ever had heat exhaustion or heat stroke?" 2. "What is the normal range for your body temperature?" 3. "Do you or any of your family members have frequent infections?" 4. "Do you or any of your family members have problems with general anesthesia?"
4
The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? -Temperature 98.6F (37C) -Pulse 72 beats/minute -Respirations 18 breaths/min -Pulse oximetry 97% -Blood pressure 146/72mmHg
74
A child sustains a greenstick fracture of the humerus from a fall out of a tree house. The nurse describes this type of fracture to the parents and should provide them with which picture? 1. Greenstick fracture 2. Spiral fracture 3. Comminuted fracture 4. Open (compound) fracture
1
A client with a known history of panic disorder comes to the emergency room and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1. Assess the client's vital signs. 2. Encourage the client to use relaxation techniques. 3. Identify the manifestations related to the panic disorder. 4. Determine wha the client's activity involved when the pain started.
1
The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75Eq/L (0.375mmol/L). Which action should the nurse take? 1. Monitor the client for irregular heart rhythms. 2. Encourage the intake of antacids with phosphate. 3. Teach the client to avoid foods high in magnesium. 4. Provide a diet of ground beef, eggs, and chicken breast.
1
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice? 1. Presence of a cephalhematoma 2. Infant blood type of O negative 3. Birth weight of 8 pounds 6 ounces 4. A negative direct Coombs' tests result
1
The nurse is caring for an obese client on a weight loss program. Which method should the nurse use to most accurately assess the program's effectiveness? 1. Monitor the client's weight. 2. Monitor the client's intake and output. 3. Calculate the client's daily caloric intake. 4. Frequently check the client's serum protein levels.
1
The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant? 1. Peeling of the skin 2. Smooth soles without creases 3. Lanugo covering the entire body 4. Vernix that cod era the body in a thick layer
1
The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction? 1. Weak pedal pulses 2. Drainage at the pin sites 3. Complaints of leg discomfort 4. Toes demonstrating a brisk capillary refill
1
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply. 1. Uterine irritability 2. Uterine tenderness 3. Painless vaginal bleeding 4. Abdominal and low back pain 5. Strong and frequent contractions 6. Nonreassuring fetal heart rate patterns
1, 2, 4, 6
The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply. 1. Headache 2. Tachycardia 3. Hypertension 4. Apprehension 5. Distended neck veins 6. A sense of impending doom
1, 2, 4, 6
The nurse is sending an arterial blood gas (ABG) specimen to the laboratory for analysis. What information should the nurse include on the laboratory requisition? Select all that apply. 1. Ventilator settings 2. A list of client allergies 3. The client's temperature 4. The date and time the specimen was drawn 5. Any supplemental oxygen the client is receiving 6. Extremity from which the specimen was obtained
1, 3, 4, 5
When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply. 1. Figs 2. Apples 3. Bananas 4. Broccoli 5. Sauerkraut 6. Baked chicken
1, 3, 5
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply. 1. Dyspnea 2. Flat neck veins 3. Nausea and vomiting 4. Chest pain or discomfort 5. Hypotension and dizziness 6. Hypertension and headache
1, 4, 5
A primary health care provider prescribes acetaminophen liquid 450mg orally every 4 hours PRN for pain. The medication label reads 160mg/5mL. The nurse prepares how many milliliters (mL) to administer one dose? Record your answer to the nearest whole number.
14mL
A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP) 85/50mmHg, pulse 96 beats per minute, respirations 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect? 1. BP 85/50mmHg, pulse 60 beats per minute, respirations 26 breaths per minute. 2. BP 98/60mmHg, pulse 80 beats per minute, respirations 24 breaths per minute. 3. BP 130/70mmHg, pulse 104 beats per minute, respirations 20 breaths per minute. 4. BP 110/40mmHg, pulse 110 beats per minute, respirations 20 breaths per minute.
2
During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report? 1. Weight gain 2. Night sweats 3. Severe lymph node pain 4. Headache with minor visual changes
2
A client admitted to the hospital has been prescribed pyridostigmine. When assessing the client for side effects of the medication, the nurse should ask the client about the presence of which occurrence? 1. Mouth ulcers 2. Muscle cramps 3. Feelings of depression 4. Unexplained weight gain
2
A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication? 1. Infuse over 1 hour and allow the client to ambulate. 2. Infuse over 1 hour with the client in a supine position. 3. Administer over 30 minutes with the client in a reclining position. 4. Administer by IV push over 15 minutes with the client in a supine position.
2
A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement? 1. Maintaining an intravenous access 2. Ensuring that oxygen is being delivered 3. Administering sedation to prevent claustrophobia 4. Providing emotional support to the client's family
2
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tension test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results? 1. Myasthenic crisis is present. 2. Cholinergic crisis is present. 3. This result is a normal finding. 4. This result is a positive finding.
2
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client? 1. Hot cocoa with honey and toast 2. Vanilla pudding and lukewarm milk 3. Hot herbal tea with graham crackers 4. Iced coffee and peanut butter and crackers
2
A client has fallen and sustained a leg injury. Which question should the nurse ask to help determine if the client sustained a fracture? 1. "Is the pain a dull ache?" 2. "Is the pain sharp and continuous?" 3. "Does the discomfort feel like a cramp?" 4. "Does the pain feel like the muscle was stretched?"
2
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition? 1. Dehydration 2. A normal finding 3. Increased intracranial pressure 4. Decreased intracranial pressure
2
A client has developed oral mucositis as a result of radiation to the head and neck. Which measure should the nurse teach the client to incorporate in a daily home care routine to help manage this condition? 1. A glass of wine per day will introduce useful bacterial to the oral cavity. 2. High-protein foods such as peanut butter should be incorporated in the diet. 3. Clean teeth and rinse mouth with a weak saline and water solution before and after each meal. 4. Oral hygiene, including brushing and flossing, should be performed in the morning and evening.
3
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for? 1. Cyanosis with accompanying pallor 2. Diffuse crackles and rhonchi on chest auscultation 3. Increase in respiratory rate from 18 to 30 breaths per minute 4. Haziness or "white-out" appearance of lungs on chest radiograph
3
A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition? 1. Hypoglycemia 2. Respiratory distress syndrome 3. Meconium aspiration syndrome 4. Transient tachypnea of the newborn
3
A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans. What should the nurse expect to note on assessment of the client? 1. Costovertebral angle pain 2. Absence of any observable signs 3. Pain, itching, and vaginal discharge 4. Proteinuria, hematuria, and hypertension
3
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which questions should the nurse ask the parent? 1. "Does the child play with an imaginary friend?" 2. "Was the child recently treated for pneumonia?" 3. "Does the child respond when called by name?" 4. "Has the child had any difficulty swallowing food?"
3
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take? 1. Ask the client to walk and observe their gait. 2. Lightly massage the calf area to relieve the pain. 3. Check the calf area for temperature, color, and size. 4. Administer PRN morphine sulfate as prescribed for postoperative pain.
3
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take? 1. Determine the need to increase the oxygen. 2. Reassure the client that there is no need to worry. 3. Conduct further assessment of the client's respiratory status. 4. Call emergency services to take the client to the emergency department.
3
The nurse has just finished assisting the primary health care provider in placing a central intravenous (IV) line. Which is a priority intervention to assure the client's safety? 1. Assessing the client's pain level 2. Assessing the client's temperature 3. Preparing the client for a chest x-ray 4. Monitoring the client's blood pressure (BP)
3
The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours. Which result should indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. A total bilirubin of 0.5mg/dL (8.5mcmol/L) 2. An erythrocyte sedimentation rate of 15mm/hour 3. A blood urea nitrogen (BUN) of 30mg/dL (10.8mmol/L) 4. A white blood cell count (WBC) of 6000mm3 (6x10^9/L)
3
A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety? 1. Use the right arm blood pressure measurement. 2. Use the fistula for all venipuncture and intravenous infusions. 3. Ensure that small clamps are attached to the AV fistula dressing. 4. Assess the fistula for the presence of a bruit and thrill every 4 hours.
4
A client has been taking a prescribed calcium channel blocker therapy for approximately 2 months. The home care nurse monitoring the effects of therapy should determine that drug tolerance has developed if which is noted in the client? 1. Decrease in weight 2. Increased joint pain 3. Output greater than intake 4. Gradual rise in blood pressure
4
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications? 1. Trim the rough edges of the cast after it is dry. 2. Weight bearing on the right leg is allowed once the cast feels dry. 3. Expect burning and tingling sensations under the cast for 3 to 4 days. 4. Keep the right ankle elevated above the heart level with pillows for 24 hours. 1. Trim the rough edges of the cast after it is dry. 2. Weight bearing on the right leg is allowed once the cast feels dry. 3. Expect burning and tingling sensations under the cast for 3 to 4 days. 4. Keep the right ankle elevated above the heart level with pillows for 24 hours.
4
A client's telemetry monitor displaces ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first? 1. Call a code 2. Prepare for cardioversion 3. Prepare to defibrillate the client 4. Check the client's level of consciousness.
4
A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action? 1. Monitor the fetal heart rate. 2. Notify the primary health care provider. 3. Transfer the client to the delivery room. 4. Place the client in the Trendelenburg position.
4
A prenatal client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding should the nurse expect to note as a result of this condition? 1. Dehydration 2. Overhydration 3. A high hematocrit level 4. A low hemoglobin level
4
