sophie test

An adolescent receives a prescription for an injection of S-matriptan succinate, 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/0.5 ml, how many ml should the nurse administer? (nearest hundredth)

0.33 ml

A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer?

0.4 ml

The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 ml bottle is labeled, 100 mg/5 ml (20 mg/ml), and is packed with a calibrated oral syringe to provide accurate dose measurements. How many ml should the nurse administer?

1.9 ml

A client is receiving an IV solution labeled Heparin Sodium 20,000 units in 5% Dextrose Injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

1000 units/hour

The healthcare provider prescribes diltiazem (Cardizem) for a child with hypertension who weighs 66 pounds. Based on the recommended dose of 3.5 mg/kg/day, how many mg should the child receive per day?

105 mg/day

A client is currently receiving an infusion labeled Heparin Sodium 25,00 units in 5% Dextrose Injection 500 ml at 14 ml/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many ml.hour?

18 ml/hour

A client receives a prescription for bacitracin 20,000 units every 12 hours IM. The medication is available in a vial that contains 50,000 units and includes reconstitution instructions: "Use 4.8 ml diluent to yield a total volume of 5 ml." How many ml should the nurse administer?

2 ml

A client with a psychotic disorder is receiving haloperidol (Haldol) 3 mg IM q30 minutes x 3 hours for agitation control. The medication is available in 5 mg/ml. How many ml will the client receive over the next 3 hours?

3.6 ml

Sodium nitroprusside (Nipride) at 0.8 mcg/kg/minute is prescribed for a client who weighs 65 kg. The available IV solution is labeled Nipride 50 mg in 500 ml D5W. The nurse should program the infusion pump to deliver how many ml/hour?

31 ml/hour

After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides home care instruction to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions? A. "Chest physiotherapy should be performed twice a day before a meal." B. "Administer a cough suppressant every 8 hours.' C. "Maintain supplemental oxygen at 4 to 6 L/minute." D. "Energy should be conserved by scheduling minimally strenuous activities."

A. "Chest physiotherapy should be performed twice a day before a meal."

A female client is seen in the Emergency Department with a broken arm. She is visibly anxious and tells the nurse "I am afraid my husband is going to kill me. The beatings are getting worse, and everyone says I should leave him, but I am afraid of what he will do to me and the children if I do leave." What question is most important for the nurse to ask the client? A. "Have you thought about what to do when you are in an unsafe situation?" B. "Have you considered attending family violence programs sponsored by the police department?" C. "Do you know a clergy person you can talk to?" D. "Did you experience violence in your family of origin?"

A. "Have you thought about what to do when you are in an unsafe situation?"

The nurse on a busy surgical unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client is best to assign to the PN? A. A preoperative client who has developed urinary retention and need a urinary catheter inserted B. A postoperative client who is receiving a unit of packed red blood cells C. A preoperative client who is fearful and anxious about the impending surgery D. A postoperative client who is febrile, has a productive cough, and is complaining of pain

A. A preoperative client who has developed urinary retention and need a urinary catheter inserted

The nurse is assessing several clients at a homeless shelter. Which client(s) should the nurse refer for involuntary admission to a psychiatric facility? (select all that apply) A. A young adult who has lost his appetite because the communists are asking him to kill all conservative Catholics B. An adult male who has not eaten for three days and says he is Jesus Christ and that God loves all people C. An older woman who used to be a prostitute and resides in the shelter about three nights weekly D. A middle-aged woman who sits for long periods of time and mumbles to herself about wanting to die E. An adolescent male who works on the streets as a beggar to purchase marijuana, food, and shelter

A. A young adult who has lost his appetite because the communists are asking him to kill all conservative Catholics B. An adult male who has not eaten for three days and says he is Jesus Christ and that God loves all people D. A middle-aged woman who sits for long periods of time and mumbles to herself about wanting to die

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's Disease. The nurse observes that whatever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? A. Affirm that the UAP is using an effective strategy to reduce the client's anxiety B. Meet with the UAP later to role model more assertive communication techniques C. Assume care of the client to ensure that effective communication is maintained D. Tell the UAP to offer more choices during the personal care to prevent anxiety

A. Affirm that the UAP is using an effective strategy to reduce the client's anxiety

A charge nurse is establishing priorities of client needs at the beginning of the morning shift. Which client situation has the highest priority for immediate care? A. An elderly client who is trying to climb over the side rails B. A diabetic client who requires insulin before breakfast C. A postoperative client with unremitting nausea D. A 5-year-old child who is crying because the parents left

A. An elderly client who is trying to climb over the side rails

An elderly male client tells the nurse that he often wakes up during the night. What action should the nurse implement first? A. Ask the client to describe what happens when he awakens B. Encourage the client to describe his bedtime routines and habits C. Instruct the client to keep a daily sleep journal for one week D. Reassure the client that sleep needs often decrease with age

A. Ask the client to describe what happens when he awakens

What nursing intervention is particularly indicated for the second stage of labor? A. Assisting the client to push effectively so that expulsion of the fetus can be achieved B. Providing pain medication to increase the client's tolerance of labor pains C. Assessing the fetal heart rate and pattern for signs of fetal distress D. Monitoring effects of oxytocin administration to help achieve cervical dilation

A. Assisting the client to push effectively so that expulsion of the fetus can be achieved

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused y deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? (select all that apply) A. Avoid prolonged standing or sitting B. Maintain the bed flat while sleeping C. Cross legs at knee but not at ankle D. Continue wearing elastic stockings E. Use recliner for long periods of sitting

A. Avoid prolonged standing or sitting D. Continue wearing elastic stockings E. Use recliner for long periods of sitting

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? A. Call respiratory therapy B. Begin manual ventilation immediately C. Monitor oxygen saturation levels q5 minutes D. Silence the alarm and call the technician

A. Call respiratory therapy

During morning rounds, the nurse finds a client who has no spontaneous respirations and does not respond to shaking. The nurse activates the "Code-Blue" system. While waiting for the code team to arrive, what action should the nurse implement? A. Check the pulse for 10 seconds and begin chest compressions B. Check the airway for a foreign body and remove it if visualized C. Assess blood pressure and pupillary response to light D. Seal the face mask of an Ambu bag over the client's mouth and nose

A. Check the pulse for 10 seconds and begin chest compressions

The nurse plans to obtain a urine specimen for culture from a client's indwelling catheter. The nurse enters the room with the syringe and notes that there is 100 ml of urine in the drainage bag, but no urine is in the tubing. What action should the nurse take? A. Clamp the tubing until urine is observed in the tubing B. Obtain sterile normal saline to irrigate the catheter C. Separate the tubing from the catheter and withdraw a urine specimen D. Remove the urine specimen from the drainage bag

A. Clamp the tubing until urine is observed in the tubing

One year after diagnosed with Pneumocystis carinii pneumonia, a client is admitted with respiratory failure. Respirations are shallow with periods of apnea. After the healthcare provider delivers a grim prognosis to the client's family, which intervention should the nurse implement first? A. Clarify client's end of life wishes B. Review client's CD4 cell count C. Obtain arterial blood gases D. Assist with insertion of an airway

A. Clarify client's end of life wishes

Before administering a parenteral nutrition through a central vein, the should confirm information from which sources? (select all that apply) A. Client's identification band B. Healthcare providers prescription C. Dietician's progress notes D. Solution label E. Measured residual volume F. Medication administration record

A. Client's identification band B. Healthcare providers prescription D. Solution label F. Medication administration record

A male client with chronic asthma tells the nurse that he is having more episodes of bronchoconstriction and increased mucous production. Which action should the nurse implement? A. Determine if rescue inhaler is being used first during an acute episodes. B. Inquire about effectiveness of corticosteroid inhaler during pollen days C. Auscultate lungs for adventitious sounds consistent with fluid accumulation D. Ask if an environmental trigger is associated with the asthmatic episodes

A. Determine if rescue inhaler is being used first during an acute episodes.

The register nurse (RN) is observing a newly hired practical nurse (PN) give a newborn a vitamin K (AquaMEPHYTON) injection. The PN uses a filter need to draw 0.25 ml of AquaMEPHYTON into the syringe, cleanses the thigh with alcohol in a circular motion, and prepares to inject the needle at a 90 degree angle in the left vastus lateralis. What action should the RN take? A. Direct the PN to change the filter needle to a 1/2 inch needle B. Confirm that the correct injection technique is being used C. Suggest injecting the medication into the dorsogluteal muscle D. Recommend administration of the injection at a 45 degree angle

A. Direct the PN to change the filter needle to a 1/2 inch needle

The nurse is preparing to administer 1.6 ml of medication IM to a 4-month-old infant. Which intervention should the nurse implement? A. Divide the medication into two injections with volumes under 1 ml B. Inject into the center one-third of the medical aspect of the thigh C. Administer into the ventrogluteal muscle with child prone D. Apply a topical anesthetic ointment prior to the injection

A. Divide the medication into two injections with volumes under 1 ml

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? A. Document the extent of he bruising in the medical record B. Assign a UAP to take vital sign measurements q1h C. Advise the client that anticoagulation therapy may be needed. D. Call the lab to obtain a stat APTT and prothrombin time

A. Document the extent of he bruising in the medical record

To prevent infection by autocontamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement? A. Dress each wound separately B. Avoid sharing equipment between multiple clients C. Use gown, mask, and gloves with dressing change D. Implement protective isolation

A. Dress each wound separately

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? A. Explain that memory loss and confusion are common with Vitamin B12 deficiency B. Ask if the client is experiencing any change in bowel habits C. Determine if the client is taking iron and folic aid supplements D. Encourage the husband to bring the client to the clinic for a complete blood count

A. Explain that memory loss and confusion are common with Vitamin B12 deficiency

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (select all that apply) A. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors B. Large protruding eyeballs are a sign of hyperthyroid function C. Early treatment includes levothyroxine D. T3 and T4 hormone levels are increased E. Weight gain is a common complaint in hyperthyroidism

A. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors B. Large protruding eyeballs are a sign of hyperthyroid function D. T3 and T4 hormone levels are increased

Which menu selection by a male client indicates to the nurse that he understands the dietary management of Crohn's disease? A. Grilled chicken sandwich and pasta B. Tossed green salad and breadsticks C. Cheese enchiladas and beans D. Hamburger and French fries

A. Grilled chicken sandwich and pasta

The mother reports to the nurse that the thick honey-colored crusts on her child's legs began as flat red spots. This is highly indicative of what condition? A. Impetigo B. Eczema C. Ringworm D. Psoriasis

A. Impetigo

A client is admitted voluntarily to the in-patient psychiatric unit for multi-substance dependency. While the client is in a group therapy, a peace officer approaches the nurse's station demanding to arrest the client. How should the nurse respond? A. Inform the officer that client information cannot be released B. Ensure safety for other client's by handcuffing the client during removal C. Refer the peace officer to the client's healthcare provider D. Call the unit security code and have the peace officer escorted off the unit.

A. Inform the officer that client information cannot be released

A nurse is admitting a 4-month-old who has respiratory syncytial virus (RIS). What intervention should the nurse implement first? A. Initiate contact precautions B. Place the infant under a mist tent C. Elevate aretial blood gases D. Obtain the infants vital signs

A. Initiate contact precautions

A male client with major depression who is taking fluoxetine calls the psychiatric clinic complaining of be more agitated, irritable, and anxious than usual. Which intervention should the nurse implement? A. Instruct the client to seek medical attention immediately. B. Explain that these are common side effects of Prozac. C. Encourage him to take the fluoxetine at night with a snack. D. Tell the client to have a complete blood count (CBC) drawn.

A. Instruct the client to seek medical attention immediately. Agitation, irritability, anxiety, and mania are early signs of serotonin syndrome, a rare but fatal reaction to SSRIs, so the client should seek medical attention immediately.

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? A. Intravenous administration of thyroid hormones B. Oral administration of hypnotic agents C. Intravenous bolus of hydrocortisone D. Subcutaneous administration of vitamin K

A. Intravenous administration of thyroid hormones

The school nurse is planning to begin an obesity screening program in a school system. It is best to begin the screening program with which group? A. Kindergarden B. Third grade C. High school D. Onset of puberty

A. Kindergarden

Which activity is best for the nurse to initiate with a depressed client? A. Make cut-out cookies B. Play chess C. Play volleyball D. Watch television

A. Make cut-out cookies

An older female who ambulates with a quad-cane prefers to use a wheelchair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (select all that apply) A. Move personal items within client's reach B. Lower bed to the lowest possible position C. Raise all bed rails when client is resting D. Give directions to call for assistance E. Assist client to the bathroom q 2 hours F. Encourage the use of the wheelchair

A. Move personal items within client's reach B. Lower bed to the lowest possible position D. Give directions to call for assistance E. Assist client to the bathroom q 2 hours

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? A. Muscle spasms of the back and neck B. Rocks back and forth in the chair C. Shuffling gait and stooped posture D. Lip smacking and frequent eye blinking

A. Muscle spasms of the back and neck

While caring for a client with a new onset of diabetes mellitus, which intervention is most important for the nurse to include in the client's plan of care? A. Observe client's glucose self-monitoring technique B. Provide written diabetic diet instructions C. Teach client how to read food labels D. Check accuracy of glucose monitoring equipment

A. Observe client's glucose self-monitoring technique

A 15-year-old client with a spinal cord injury develops spastic leg tremors, sweating, and a headache. Which action should the nurse implement? A. Palpate the bladder for distention B. Obtain an oxygen saturation level C. Administer a prescribed analgesic D. Encourage dorsiflexion of the feet

A. Palpate the bladder for distention

A client with an electrical burn is admitted to the emergency department on a backboard with a cervical collar. Which intervention should the nurse implement? A. Place the client on cardiac telemetry B. Obtain STAT arterial blood gases C. Flush the burned area with sterile normal saline D. Elevate the client's head of bed to 45 degrees

A. Place the client on cardiac telemetry

An older male adult resident of an extended care facility receives a prescription for diphenhydramine (Benadryl) 25 mg PO to treat generalized pruritus. Two hours after administration of the drug, he continues to experience itching, is confused, and has an unsteady gait. What action should the nurse implement first? A. Place the client on fall precautions B. Apply soft limb restraints to extremities C. Give a second dose of Benadryl D. Lubricate the skin with an emollient

A. Place the client on fall precautions

The nurse is caring for a one-week infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? (select all that apply) A. Poor feeding and vomiting B. Leakage of CSF form the incisional site C. Hyperactive bowel sounds D. Abdominal distension E. White blood cell count of 10, 000/mm^3

A. Poor feeding and vomiting B. Leakage of CSF form the incisional site D. Abdominal distension

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collections device. The client's vital sign are: blood pressure 80/40 mmHg, heart rate 120 beats/minute, respiratory rate 32 breaths/minute, oxygen saturation 88%. Which interventions should the nurse implement? (select all that apply) A. Provide supplemental oxygen B. Auscultate bilateral lung fields C. Administer a nebulizer treatment D. Reinforce occlusive CT dressing E. Give PRN dose of pain medication

A. Provide supplemental oxygen B. Auscultate bilateral lung fields D. Reinforce occlusive CT dressing

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. What action should the nurse take? A. Remind the UAP to continue rubbing the hands together until they dry B. Supervise the UAP in the next client's room to evaluate hand hygiene C. Instruct the UAP to return to the clients room to perform hand washing D. Advise the UAP to wear gloves when obtaining vital signs for all clients

A. Remind the UAP to continue rubbing the hands together until they dry

The legs of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personnel (UAP) place a heating pad on the mottled areas, what action should the nurse take? A. Remove the heating pads and pace a soft blanket over the client's legs and feet B. Advise the UAP to observe the client's skin while the heating pads are in place C. Evaluate the client's feet on a pillow and monitor the client's pedal pulses frequently D. Instruct the UAP to reposition the heating pads to the sides of the legs and feet

A. Remove the heating pads and pace a soft blanket over the client's legs and feet

What modification is most important for the nurse to recommend to a client with high cholesterol? A. Replace beed with fish or poultry B. Include six servings of fruits and vegetables daily C. Limit portion sizes using the "Plate Method" D. Use vegetables oils in food preparation

A. Replace beed with fish or poultry

A client who had a below-the-knee amputation is experiencing severe phantom limb pain (PLP) and asks the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? A. Research indicated that mirror therapy is effective in reducing phantom limb pain B. You can try mirror therapy, but do not expect complete elimination of the pain C. Transcutaneous electrical nerve stimulation (TENS) has been found to be more effective D. Where did you learn about the use of mirror therapy in treating phantom limb pain?

A. Research indicated that mirror therapy is effective in reducing phantom limb pain

The scrub nurse places the fenestrated drapes to expose the operative area for a client who is having a hepatic tumor removed. The scrub nurse should assist with applying the sterile impermeable adhesive drape or surgical skin barrier to which area? A. Right subcostal B. Right lumbar C. Low transverse D. Midline abdominal

A. Right subcostal

The DASH (Dietary Approaches to Stop Hypertension) diet is prescribed for a client with uncontrolled hypertension. Which dietary choices should the nurse instruct the client to eat? A. Shredded wheat B. Avocado salad with olives C. Cheddar cheese D. Canned roasted almonds

A. Shredded wheat

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? A. Stabilize the victim's neck and roll over to evaluate his status B. Examine the victim's body surfaces for arterial bleeding C. Open the airway and initiate resuscitative measures D. Return to the car to call emergency response 911 for help

A. Stabilize the victim's neck and roll over to evaluate his status

A young woman is preparing to leave for a 7-day boat trip. She requests a prescription for motion sickness, so the healthcare provider prescribes meclizine (Antivert). Which instruction should the nurse include in this client's teaching? A. Suck on hard candy for a dry mouth while taking this drug B. Sit upright for at least 30 minutes after taken this drug C. Avoid eating shellfish for 24 hours after taking this drug D. Do not drink caffeinated beverages while taking this drug

A. Suck on hard candy for a dry mouth while taking this drug

A client with Type 1 diabetes mellitus (DM) is admitted for an emergency cholecystectomy. To prevent diabetic ketoacidosis (DKA), which intervention is most important for the nurse to implement? A. Supplement insulin needs using a sliding scale B. Monitor the client for polyuria and dehydration C. Measure urine ketones when blood glucose exceeds 300 mg/dl D. Teach the client to monitor blood glucose levels frequently when ill

A. Supplement insulin needs using a sliding scale

Which expected outcome statement should the nurse include in a teaching plan designed to assist a client with management of an acute attack of gout? A. The client will avoid use of alcohol in managing stress. B. The client will implement a high-purine daily dietary regime. C. The client will use local heat applications for acute pain. D. The client will stop antigout medication once pain subsides.

A. The client will avoid use of alcohol in managing stress. Gout, an error in purine metabolism or excretion that results in urate crystal disposition usually in a joint of the great toe, causes acute joint inflammation and severe pain. Alcohol consumption should be avoided because it increases production or uric acid and prevents excretion

The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires immediate intervention by the nurse? A. The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her. B. A client with depression who is crying and tells the nurse that he has has suicidal thoughts C. A young adult diagnosed with a somatoform disorder reports having a severe headache that has become unbearable D. An adult heroin abuser who reports the onset of withdrawal and requests a refill for a prescription for methadone

A. The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her.

A client in septic shock jas a double lumen central venous catheter with one liter of 0.9% Normal Saline solution infusing at 1 ml/hour through one lumen and Total Parenteral Nutrition (TPN) Infusing at 50 ml/hour through one port. The nurse prepares newly prescribed IV antibiotics that should take 45 minutes to infuse. What intervention should the nurse implement? A. Use a secondary port of the Normal Saline solution to administer the antibiotic B. Add the antibiotic to the TPN solution, and continue the normal saline solution C. Stop the TPN infusion for the time needed to administer the prescribed antibiotic D. Add the antibiotic to the Normal Saline solution and continue both infusions

A. Use a secondary port of the Normal Saline solution to administer the antibiotic

The nurse is investigating a client injury that occurred when a mechanical lift malfunctioned while moving a client from the bed to a orthopedic-chair. Which question should the nurse ask first? A. Was the equipment used according to policy? B. Which day of the week did the injury occur? C. When was the lift last checked by maintenance? D. What mitigating circumstances led to the injury?

A. Was the equipment used according to policy?

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? A. Withhold food and fluid intake B. Initiate IV fluid replacement C. Administer antiemetics as needed D. Evaluate intake and output ratio

A. Withhold food and fluid intake

In making client care assignments, which client is best to assign to the practical nurse (PN) working on the unit with a nurse? A. an immobile client receiving low molecular weight heparin Q12H B. a client who is receiving a continuous infusion of heparin and gets out of bed BID C. A client how is being titrated off a heparin infusion and started on PO warfarin D. An ambulatory client receiving warfarin with an INR of 5 seconds.

A. an immobile client receiving low molecular weight heparin Q12H

the healthcare provider is working with a client who was recently diagnosed with asthma. Which statement by the client indicates to the nurse that further teaching is needed? A. "It is normal for my heart rate to increase slightly when I use my albuterol inhaler." B. "I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler." C. "I should wait several minutes between puffs of my inhalers." D. "My albuterol can be used between regular doses if I experience difficulty breathing."

B. "I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler."

The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis? A. Body mass index (BMI) of 31 B. 20 pack-year history of cigarette smoking C. Birth control pill usage until age 45 D. Diabetes mellitus in family history

B. 20 pack-year history of cigarette smoking

Which client situation requires the most immediate intervention by the nurse? A. One day after surgery, a client complains of unpleasant flatulence B. A bedfast client experiences an episode of urinary incontinence C. An ambulatory client reports the onset of stress incontinence D. A client receiving regular dose of an opioid develops constipation

B. A bedfast client experiences an episode of urinary incontinence

Which client situation requires the most immediate intervention by the nurse? A. One day day after surgery, a client complains of unpleasant flatulence. B. A bedfast client experiences an episode of urinary incontinence. C. An ambulatory client reports the onset of stress incontinence. D. A client receiving regular dosage of an opioid develops constipation

B. A bedfast client experiences an episode of urinary incontinence.

A newly graduated and licensed registered nurse (RN) is in the second day of orientation to the hospital unit. The education director tells the charge nurse that the new graduate should be assigned to care for one client. Which client is best for the nurse to assign to this new graduate? A. A client returning from surgery following a bowel resection B. A client who is 4-days post myocardial infraction C. A 6-day postoperative client who is receiving a blood transfusion D. A client with AIDS who is in the final stages of dying

B. A client who is 4-days post myocardial infraction

After reviewing the Braden Scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? A. An older adult who is unable to communicate elimination needs B. A older man who sheets are damp each time he turned C. A woman with osteoporosis who is unable to bear weight D. A poorly nourished client who requires liquid supplements

B. A older man who sheets are damp each time he turned

A 7-year-old child admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain? A. A recent DPT immunization B. A recent strep throat infection C. High blood cholesterol levels on routine screening D. Increased thirst and urination

B. A recent strep throat infection

A female resident of a long-term care facility is being admitted to the medical department. The client has a fractured humerus and methicillin-resistant staphylococcus aureus (MRSA). Which room should the charge nurse assign this client? A. A private room, and institute protective environment measures B. A semi-private room with a another client who also has MRSA C. A private isolation room with a vented negative airflow system D. A semi-private room with a client who has hepatitis B (HBV)

B. A semi-private room with a another client who also has MRSA

The nurse who is performing blood sugar and cholesterol screenings at a community health fair determines that a female client's blood sugar is 59 mg/dl at 10:00 a.m. Which nursing intervention is most important for the nurse to implement? A. Check the client's cholesterol B. Ask the client how she's feeling C. Take the client's blood pressure D. Encourage the client to rest

B. Ask the client how she's feeling

While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tell the nurse that her family has stopped calling and visiting. What action should the nurse take first? A. Determine the client's orientation to time and space B. Ask the client when a family member last visited her C. Review the client's record regarding social interactions D. Reassure the client of her family's love for her

B. Ask the client when a family member last visited her

An elderly client is experiencing disturbed sleep patterns. Which interventions should the nurse implement to help the client attain maximal sleep function? (select all that apply) A. Discuss need for adult day services B. Assess daytime somnolence C. Recommend evaluation of home safety D. Review medication side effect profiles E. Refer to social worker for elder care

B. Assess daytime somnolence D. Review medication side effect profiles

Thirty-six hours after cesarean delivery, a client complains of nausea and bloating. Assessment reveals a distended abdomen and no bowel movement since delivery. What intervention should the nurse implement first? A. Increase fiber in diet B. Auscultate the abdomen C. Insert a rectal tube D. Encourage ambulation

B. Auscultate the abdomen

During the transfer of a client who had major abdominal surgery this morning, the postanesthesia care unit (PACU) nurse reports that the client, who is awake and responsive, continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 minutes ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? A. Situation B. Background C. Assessment D. Recommendation E. Rationales

B. Background C. Assessment D. Recommendation

An older male client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) is on strict bedrest, and asks the nurse, "Why can't I get out of bed? What response is best for the nurse to provide? A. A high-Fowler's position promotes lung expansion B. Bed rest decreases your body's need for oxygen C. You are so weak that you are at risk for falling D. hospital policy requires that you are assisted to get up

B. Bed rest decreases your body's need for oxygen

In monitoring a client receiving propylthiouracil (PTU) for hyperthyroidism, an increase in which finding indicates that the medication is producing the desired effect? A. Urinary output B. Body weight C. Pulse rate D. Blood pressure

B. Body weight

At 1000 the healthcare provider prescribes an increase dose in the dosage of a client's loop diuretic from 40 mg to 80 mg a day. The nurse has already administered today's 40 mg dose of the loop diuretic at 0600. Which action should the nurse implement? A. Schedule the second 40 mg of the diuretic for administration at 1800 that evening B. Clarify the start date of the new dose with the healthcare provider C. Administer an additional 40 mg of the diuretic after checking the serum potassium level D. Implement the increase in the prescribed dosage the following morning

B. Clarify the start date of the new dose with the healthcare provider

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider? A. elevated liver function tests B. Decreased white blood cell count C. Vomiting and diarrhea D. Pruritus and muscle aches

B. Decreased white blood cell count

Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range of motion B. Distal pulse intensity C. Extremity sensation D. Presence of exudate

B. Distal pulse intensity

The new mother tells the nurse that she does not want her newborn to receive any immunizations. It is the hospital's policy to routinely administer immunizations to all newborns. What intervention should the nurse implement? A. Advise the mother to sign out of the hospital AMA if wishing to refuse the immunizations B. Document that the mother has refused immunization permission for the newborn C. Administer the immunizations after first explaining the hospital policy to the mother D. Report the immunization status of the infant to the office of child protective services

B. Document that the mother has refused immunization permission for the newborn

The nurse observes that a client with COPD is exhibiting fingernail clubbing. What action should the nurse take? A. Administer a PRN dose of albuterol (Proventil) via inhaler. B. Document the assessment finding in the nurses' notes C. Assist the client to a tripod position in the bed. D. Increase the client's oxygen from 1 to 2 liters per minute.

B. Document the assessment finding in the nurses' notes

The nurse is giving medication to an older client who has a percutaneous esophageal gastrostomy (PEG) tube in place. Which medication drug form should the nurse question? A. Digoxin (Lanoxin) tablet B. Enteric-coated aspirin (Ecotrin) C. Furosidemide (Lasix) tablet D. Megestrol (Megace) suspension

B. Enteric-coated aspirin (Ecotrin)

A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? A. Reschedule the client's appointment for the following day B. Explain that this normal secretion can be assessed at the next visit C. Tell the client to begin nipple stimulation to prepare for breast feeding D. Recommend that the client start wearing a supportive brassiere

B. Explain that this normal secretion can be assessed at the next visit

Two months after treatment with radioactive iodine (I131) (RAI) for hyperthyroidism, a male client reports the onset of extreme fatigue, depression, and hair loss. What action should the nurse take? A. Confirm that the client should continue to take his anti-thyroid medication B. Explain to the client that thyroid replacement hormones may be needed. C. Advise the client to increase his caloric intake and eat high protein foods D. Assure the client that these are time-limited side effects of the treatment

B. Explain to the client that thyroid replacement hormones may be needed.

The nurse caring for a client with dysphagia is attempting to insert a nasogastric tube (NGT), but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus? A. Offer the client sips of water or ice and coax to swallow B. Flex the client's head with chin to the chest and insert C. Elevate the bed 90 degrees and hyperextend the head D. Push the NGT beyond the oropharynx gently yet swiftly

B. Flex the client's head with chin to the chest and insert

A male client with chronic alcohol use is admitted with signs of early cirrhosis. Which nursing action should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Assist client with preferred meal selections B. Gather oral hygiene products for client's use C. Evaluate client for asterixis D. Assess the client for ascites

B. Gather oral hygiene products for client's use

When completing a mental health assessment, the nurse wishes to obtain information about a client's insight and judgement. What interview technique is most useful in assessing these mental abilities? A. Ask the client to describe what is meant by the proverb, "A penny saved is a penny earned." B. Have the client describe what should be done if a child was observed alone in a locked car on a hot day C. Show the client a list of 3 words a the beginning of the interview, and ask for word recall later. D. Request that the client complete a mathematical operation, such as counting backward by 9s form 100

B. Have the client describe what should be done if a child was observed alone in a locked car on a hot day

The nurse is triaging clients in an urgent car clinic. The client with which symptoms should be referred to the health care provider immediately? A. High fever, skin rash, and a productive cough B. Headache, photophobia, and nuchal rigidity C. Nausea, vomiting, and poor skin turgor D. Malaise, fever, and stiff, swollen joints

B. Headache, photophobia, and nuchal rigidity

In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? A.Elevated parathyroid hormone level B. Hematocrit of 28% C. Heart rate of 92 beats per minute D. Systolic murmur

B. Hematocrit of 28%

During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings incidence of otitis media? A. Pneumococcal vaccine B. Hemophilus Influenza type B (H1B) vaccine C. Palrvizumab vaccine for RSV D. Varicella Virus Vaccine Live

B. Hemophilus Influenza type B (H1B) vaccine

An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic stage of bipolar disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been "trying to start a new business" and "too busy to eat." He is alert and oriented to time, place, and person, but not situation. Which nursing problem has the greatest priority? A. Hygiene self-care deficit B. Imbalanced nutrition C. Disturbed sleep pattern D. Self neglect

B. Imbalanced nutrition

As a means of relieving a client's pain associated with osteoarthritis, the nurse plans to provide local rest. To implement this intervention, which action should the nurse take? A. Elevate the affected joint with an icepack on it B. Immobilize the affected joint with a splint C. Administer a prescribed local topical salicylate D. Maintain bedrest with bathroom privileges

B. Immobilize the affected joint with a splint

In monitoring a client's respiratory stauts, which symptom is characteristic of early acute (adult) respiratory distress syndrome (ARDS)? A. Coarse breath sounds B. Increased respiratory rate C. Intercostal retractions D. Pleural friction rubs

B. Increased respiratory rate

During a home visit, the nurse determines that a male client is experiencing symptoms that should be controlled by his prescribed medication. The client states that he forgot when he was supposed to take his medication. What is the priority nursing problem when the nurse develops the plan of care for the client? A. Self neglect related to loss of cognitive function B. Ineffective health maintenance related to lack of knowledge C. Situational low self-esteem related to symptoms of illness D. Noncompliance related to lifestyle change

B. Ineffective health maintenance related to lack of knowledge

An adult male who returned from a vacation in Mexico three weeks ago calls the clinic complaining of abdominal pain, weight loss, and diarrhea. What action should the nurse take? A. Encourage the client to go to the emergency room B. Instruct the client to bring in a stool sample C. Ask the client if he is experiencing dyspnea D. Tell the client to eat toast and Gatorade sports drink

B. Instruct the client to bring in a stool sample

When assessing a client who had a supratentorial craniotomy, what action should the nurse implement when determining the client's Glasgow coma scale (GCS) rating? A. Inject cold water into the client's ear. B. Instruct the client to raise an arm C. Determine the intracranial pressure D. Check the patellar and radial reflexes

B. Instruct the client to raise an arm

A male client with Addison's disease tells the nurse that he is taking hydrocortisone in a divided daily dose. He reports increasing fatigue and weakness. What action should the nurse take? A. Advise the client to skip the next scheduled dose of hydrocortisone B. Interview the client about any sources of increased stress in his life C. Instruct the client to limit his intake of oral fluids, especially at night D. Encourage the client to increase daily exercise and physical activity

B. Interview the client about any sources of increased stress in his life

A client with Alzheimer's Disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? A. Urinary incontinence B. Left forearm hematoma C. Disorientation to surroundings D. Dislodged intravenous site

B. Left forearm hematoma

What intervention should the nurse implement to prevent edema and promote healing of a client's incision resulting from an above-the-knee amputation? A. Keep the residual limb in a dependent position B. Maintain the residual limb in a compression dressing C. Inspect the incision hourly for the first 24 hours postoperatively D. Elevate the affected limb on two pillows at all times

B. Maintain the residual limb in a compression dressing

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restraints are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? A. Understands pain management scale B. Maintains effective breathing patterns C. Absence of ventilator associated pneumonia D. No injuries related to soft restraints occur

B. Maintains effective breathing patterns

The nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goal is most important to include in this client's plan of care? A. Implement decisions about future hospice services within the next 3 months B. Maintains pain level below 4 when implementing outpatient pain clinic strategies C. Requests home health care if independence becomes compromised for 5 days D. Arranges for short term counseling if stressors impact work schedule for 2 weeks

B. Maintains pain level below 4 when implementing outpatient pain clinic strategies

The nurse makes a supervisory home visit to observes an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's Disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? A. Affirm that the UAP is using an effective strategy to reduce the client's anxiety B. Meet with the UAP later to role model more assertive communication techniques C. Assume care of the client to ensure that the effective communication is maintained D. Tell the UAP to offer more choices during the personal care to prevent anxiety

B. Meet with the UAP later to role model more assertive communication techniques

A male client with hepatitis A is admitted with elevated hepatic enzymes and jaundice. Which intervention should the nurse implement? A. Provide cloth gowns for the client to wear B. Meticulous hand washing after each client contact C. Place the client in strict airborne precautions D. Use plastic utensils with each meal tray

B. Meticulous hand washing after each client contact

The nurse learns that a client in a semi-private room has a postoperative wound that is colonized with a multi-drug resistant organism. What action should the nurse implement? A. Maintain standard precautions and place the roommate in protective isolation B. Move the client to a private room and implement contact precautions for the client C. Initiate airborne precautions for both clients, leaving the in the semi-private room D. Begin droplet precautions for both clients before moving them to private rooms

B. Move the client to a private room and implement contact precautions for the client

A client with superficial burn to the face, neck. and hands resulting from a house fire is admitted to the burn unit. Which assessment finding indicated to the nurse that the client should be monitored for carbon monoxide poisoning? A. Expiratory stridor and nasal flaring B. Mucus membrane cherry red color C. Carbonaceous particles in sputum D. Pulse oximetry reading of 80 percent

B. Mucus membrane cherry red color

The nurse observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What action should the nurse perform first? A. Determine the client's blood pressure and apical pulse rate B. Observe the amount of urine in the client's drainage bag C. Obtain a pulse oximeter to assess the client's oxygen saturation D. Review the medication record for recently administered medications

B. Observe the amount of urine in the client's drainage bag

A client with a peripherally inserted central venous catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? A. Gently palpate the neck for tenderness B. Observe the antecubital fossa for inflammation C. Check for drainage in the subclavian area D. Measure for any increase in abdominal girth

B. Observe the antecubital fossa for inflammation Peripherally inserted central catheters are threaded into the basilic vein at the antecubital area. If the client develops a fever, the nurse should assess for signs of an infection at the insertion site of the catheter

The nurse is assessing an infant on admission to the newborn nursery and finds that both brachial pulses are bounding, but bilateral femoral pulses are only slightly palpable. Which assessment should the nurse implement next? A. Assess heart sounds for a murmur B. Obtain blood pressures in all extremities C. Listen to the lung fields for fine crackles D. Elevate the legs for evidence of edema

B. Obtain blood pressures in all extremities

The nurse manager is concerned about the number of falls that have occurred on the unit in the last month. Which action is most likely to decrease the number of falls? A. Place all clients on the unit regardless of age at risk for falls B. Obtain the evidence based practice guidelines for fall prevention C. Determine if pain medication is related to those who fell D. Inquire about what other units are doing to prevent falls

B. Obtain the evidence based practice guidelines for fall prevention

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen firm a female client. After positioning and prepping the client, rank the actions in the sequence they should be implemented. A. Don sterile gloves and prepare the sterile field. B. Open the sterile catheter kit close to the client's perineum C. Cleanse the urinary meatus using the solution, swabs, and forceps provided D. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

B. Open the sterile catheter kit close to the client's perineum A. Don sterile gloves and prepare the sterile field. C. Cleanse the urinary meatus using the solution, swabs, and forceps provided D. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the Dilaudid, what assessment should the nurse complete? A. Respiratory rate B. Pain scale C. Level of consciousness D. Blood pressure

B. Pain scale

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program? A. A lasting of African-American women who live in the community B. Participation of community leaders in planning the program C. Morbidity data for breast cancer in women of all races D. Techical assistacne to produce a video on breast self-examination

B. Participation of community leaders in planning the program

A clients morning laboratory test results include leukocytes 3,500/mm^3 or 3.5x10^9/L (SI). Based on the laboratory result, which complaint is this client most likely to report to the nurse? A. Inability to walk without shortness of breath B. Persistent cough with yellow-colored sputum C. Superficial cuts do not readily stop bleeding D. A red streak and pain in right calf muscle

B. Persistent cough with yellow-colored sputum The leukocyte level is below normal (WBC 5,000-10,000). WBC are integral to the body's response to infection, so the client's report of yellow-colored sputum is characteristic of purulent sputum, a sign of infection

In assessing a pressure ulcer on a client's hip, which action should the nurse include? A. Determine the degree of elasticity surrounding the lesion B. Photograph the lesion with a ruler placed next to the lesion C. Stage the depth of the ulcer using the Braden numeric scale D. Use a gloved finger to palpate for tunneling around the lesion

B. Photograph the lesion with a ruler placed next to the lesion

While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? A. Tinea corporis B. Psoriasis C. Herpes Zoster D. Drug reaction

B. Psoriasis

The nurse is caring for six clients on a medical-surgical unit. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (select all that apply) A. Assess daily weights for trends B. Record vital signs every four hours C. Assist with ambulation as prescribed D. Provide oral care after meals E. Monitor for signs of dehydration

B. Record vital signs every four hours C. Assist with ambulation as prescribed D. Provide oral care after meals

The nurse is managing clients who are mechanically ventilated. The client with which assessment finding requires the most immediate intervention by the nurse? A. Audible voice when client is trying to communicate B. Restrained and restless with a low volume alarm C. High pressure alarm when client is coughing D. Diminished breath sounds in the right posterior base

B. Restrained and restless with a low volume alarm

A male client presents to the clinic with large draining ulcers on his lower legs that are characteristic of Kapok's sarcoma lesions. He is accompanied by two family members. What actions should the nurse take? A. Ask the family members to wear gloves when touching the client B. Send family to the waiting area while the client's history is taken C. Obtain a blood sample to determine of the client is HIV positive D. Complete a head to toe assessment to identify other signs of HIV

B. Send family to the waiting area while the client's history is taken

A newborn is apnea for 20 seconds. What action should the nurse implement? A. Place oxygen cannula near the nares B. Stimulate by gently rubbing infant's trunk C. Begin cardiopulmonary resuscitation D. Suction the infant's nano-oropharynx

B. Stimulate by gently rubbing infant's trunk

A male client with chronic renal failure (CRF) is admitted to the intensive care unit after missing his last three appointments at the dialysis center. His arterial blood gas (ABG) results are: pH 7.32; PaCO2 32 mmHG; HCO3 18 mEq/L. Which assessment finding should the nurse expect this client to exhibit? A. Diaphoresis B. Tachypnea C. Hypotension D. Bradycardia

B. Tachypnea

An unlicensed assistive personnel (UAP) is teamed with a nurse who is caring for four clients. Client A is admitted to the medical unit for heart failure (HF) Client B has just returned from surgery Client C, with chronic obstructive pulmonary disease (COPD), needs new oxygen tubing Client D is waiting to be discharged Which activity should the nurse delegate to the UAP as having the highest priority? A. Obtain the daily weight for the client with HF B. Take vital signs of the client who just returned form surgery C. Gather equipment for oxygen tubing change for the client with COPD D. Assist client into the wheelchair for discharge

B. Take vital signs of the client who just returned form surgery

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action in the treatment plan should the nurse implement? A.Tell client to drive over the bridge until fear is manageable B. Teach client to listen to music or audio books while driving C. Encourage client to have spouse drive in stressful places D. Recommend that the client avoid driving over the bridge

B. Teach client to listen to music or audio books while driving

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The healthcare provider should be notified of the client's status B. The client's need for pain medication should be determined C. The chaplain should be requested to come to the client's bedside D. The client's signs of impending death should be documented

B. The client's need for pain medication should be determined

A client slips and falls while getting out of bed and the charge nurse instructs the nurse who is caring for the client to complete an incident report. What is the main purpose in having the nurse complete the incident report? A. To ensure that the nurse caring for the client takes responsibility for the incident. B. To provide computer documentation of the incident as a basis for further investigation C. To protect the nurse and the hospital against charges of malpractice D. To reprimand the nurse for not providing safe care for the client

B. To provide computer documentation of the incident as a basis for further investigation

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? A. High salt can damage the lining of the blood vessels B. Too much salt can cause the kidneys to retain fluid C. Excessive salt can cause blood vessels to contract D. Salt can cause inflammation inside the blood vessels

B. Too much salt can cause the kidneys to retain fluid

A client with dementia who is cared for at home by her husband becomes increasingly confused in the evening. Her husband reports to the home health care nurse that his wife often believes that she is waiting for the oil to be changed in her car and insists on leaving. Which recommendation should the nurse provide to this husband? A. Remind his wife that she is just a little confused B. Try to interest his wife in a different activity C. Give his wife a PRN dose of haloperidol (Haldol) D. Show his wife her car that is still in the garage

B. Try to interest his wife in a different activity

The nurse plans to collect a 24-hour urine specimen for a creatine clearance test. Which instruction should the nurse provide to the adult male client? A. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours, for the next 24 hours B. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens D. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle

B. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours

When administering medications, when is the last opportunity for the nurse to discover a near-miss medication error? A. During medication administration documentation B. When determining the client'd identity at the bedside C. After the dose is dispensed by the computer-controlled system D. As the prescription is verified with the client's medical record

B. When determining the client'd identity at the bedside

The nurse prepares to suction a client using nasotracheal suctioning. Which ongoing assessments should the nurse plan to complete while performing the procedure? A. amount of wall suction B. color of the lips C. breathing pattern D. breath sounds E. appearance of secretions

B. color of the lips C. breathing pattern E. appearance of secretions

A home health nurse is visiting a client with a history of heart failure (HF). When interviewing the client, which question provides the most useful information for the nurse? A. "Have you been weighing yourself once a month?" B. "Have you had any headaches lately?" C. "How many pillows do you sleep on at night?" D. "How much caffeine are you drinking?"

C. "How many pillows do you sleep on at night?"

The nurse is evaluating the health teaching of a female client with condyloma acuminata. Which statement by the client indicates that teaching has been effective? A. "These warts are caused by a fungus" B. "Early treatment is very effective" C. "I need to have regular pap smears" D. "I will clean my hot tub better"

C. "I need to have regular pap smears"

A 58-year-old client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide? A. "CKD stresses your body to over-secrete gastric juices, and antacids help neutralize them." B. "OK, I will let your healthcare provider know that you do not need the antacid." C. "Your serum phosphate levels are up, and aluminum antacids prevent absorption of phosphates in foods." D. "I will hold the antacids for now, and if you get indigestion, I will bring it back."

C. "Your serum phosphate levels are up, and aluminum antacids prevent absorption of phosphates in foods."

A client with a serum sodium level of 125 mEq/ml or mmol/L (SI)should benefit most from the administration of which intervention solution? A. 10% Dextrose in 0.45% sodium chloride B. 5% Dextrose in 0.2% sodium chloride C. 0.9% sodium chloride solution (normal saline) D. 0.45% sodium chloride solution (half normal saline)

C. 0.9% sodium chloride solution (normal saline)

What symptom is characteristic of ureteral colic in the clients diagnosed with renal calculi? A. Symptoms of irritation associated with urinary tract infection B. Intense, deep ache in the costovertebral region C. Acute, excruciating, wave-like pain radiating to the genitalia D. Chills, fever, and dysuria

C. Acute, excruciating, wave-like pain radiating to the genitalia

A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse's request, what action is best for the charge nurse to take? A.Since treatment is completed, assign the nurse to routine RN responsibilities B. Ask to meet with the impaired nurse's therapist before allowing her back on the unit C. All the impaired nurse to return to work and monitor medication administration D. Meet with the staff to assess their feelings about the impaired nurse's return to the unit

C. All the impaired nurse to return to work and monitor medication administration

A male client with bipolar disorder has difficulty concentrating and plans to attend group for the first time. He tells the nurse that he will try to stay for the music relaxation group. After 20 minutes in the group, he becomes restless and begins to leave. What should the nurse do? A. Ask the client to stay until the end B. Encourage the client to go to another group C. Allow the client to leave the group D. Offer the client an antianxiety medication

C. Allow the client to leave the group

The nurse is obtaining a blood sample via venipuncture from a preschool-aged child. Which intervention should the nurse implement? A. Explain in very simple terms why the blood is needed B. Encourage the child to talk about this experience C. Apply a large colored band-aid to the puncture site D. Place the labeled specimen in a paper cup for transport

C. Apply a large colored band-aid to the puncture site

About 85 victims of a train derailment are brought to the Emergency Department of a small rural hospital. An older male with extensive crush injuries to his lower extremities and pelvis has a blood pressure of 42/28, a thready pulse of 120 beats/minute, and a respiratory rate of 10 breaths/minute with periods of apnea. Using the disaster triage system, which action should the nurse take? A. Obtain the crash cart and defibrillator B. Transport to radiology department C. Assign a black triage color D. Initiate a large bore IV infusion

C. Assign a black triage color

An adult, Muslim client with ulcerative colitis was admitted to the post-surgical unit earlier today following a bowel resection with temporary colostomy. Which intervention is most important for the nurse to implement? A. Teach the client how to perform stoma care B. Allow family members to visit whenever they wish C. Assign a care provider of the same gender D. Evaluate the client's current nutritional status

C. Assign a care provider of the same gender

During a clinic visit, a male client with heart failure (HF) reports that he has gained 4 pounds (1.8 kg) in the last 3 days. Which action should the nurse implement? A. Recommend controlled portions at mealtimes B. Assess for bilateral pitting pedal edema C. Auscultate all lung fields for fine crackles D. Encourage a reduced intake of table salts

C. Auscultate all lung fields for fine crackles

A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm^3. Which intervention should the nurse include in the client's plan of care? A. Pace activities between planned rest periods. B. Monitor intake and output C. Avoid intramuscular injections D. Limit exposure to visitors with respiratory infections

C. Avoid intramuscular injections

A client taking tamoxifen citrate following a lumpectomy reports several problems to the nurse. It is most important for the nurse to follow-up on which reported problem? A. Erratic menstrual periods B. Bone pain C. Calf tenderness D. Anorexia and nausea

C. Calf tenderness

The nurse is assessing the normal development of a 9-year-old male infant. Which information should the nurse obtain from the mother? A. Has the child started to walk? B. Is the baby able to lift his head when prone? C. Can the child sit alone? D. Does the baby roll from abdomen to back?

C. Can the child sit alone?

A 12-lead electrocardiogram (ECG) indicated a ST elevation in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribes tissue plasminogen activator (t-PA). Prior to initiating the infusion, which intervention is most important for the nurse to implement? A. Place the ECG findings in the client's record B. Obtain a signed informed consent C. Complete pre-infusion checklist D. Insert two large bore IV sites

C. Complete pre-infusion checklist

An adult female client is admitted to the psychiatric unit because of a complex hand washing ritual she preforms daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's hand washing is an example of which clinical behavior? A. Obsession B. Addiction C. Compulsion D. Phobia

C. Compulsion

The preeclamptic client who delivered 24 hours ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 3 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? A. Discontinue the magnesium sulfate immediately B. Decrease the client's IV rate to 50 ml per hour C. Continue with the plan of care for this client D. Change the client's diet to NPO status

C. Continue with the plan of care for this client

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? A. Conversion of the client's PPD test from negative to positive B. Length of time of the exposure to tuberculosis C. Current diagnosis of hepatitis B D. History of intravenous drug abuse

C. Current diagnosis of hepatitis B

Which assessment finding has the highest priority when planning nursing care for a client with peptic ulcer disease (PUD)? A. Epigastric pain after eating B. Dizziness when rising form a sitting position C. Dark tarry liquid stool D. Weight loss of 10 pounds in the past month

C. Dark tarry liquid stool

The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? A. Check the client's temperature, blood sugar, and urine output B. Transport the client for laboratory and electrocardiogram (EKG) C. Delegate care of the crying client to an unlicensed assistant D. Send the client to the shelter's nutrient center to obtain water and food

C. Delegate care of the crying client to an unlicensed assistant

During assessment of a 2-year-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take? A. Ask the mother about the discoloration B. Report possible child abuse to protective services C. Document the finding in the report D. Gently rub the area with skin cream to promote healing

C. Document the finding in the report

While completing an admission assessment for a client with unstable angina, which closed ended question should the nurse ask about the client's chest pain? A. Tell me about the activities that cause your pain? B. When did you first notice the pain in your chest? C. Does your pain occur when walking short decrease? D. How do you feel when the pain becomes noticeable?

C. Does your pain occur when walking short decrease?

A client's serum potassium test level is 6 mEq/L. The laboratory indicates, "Specimen is hemolyzed." What action should the nurse take? A. Encourage the client to eat a banana B. Notify the healthcare provider of the laboratory finding C. Draw a new blood specimen D. Obtain a prescription for sodium polystyrene sulfonate (Kayexalate)

C. Draw a new blood specimen

The nurse initiates a one-to-one relationship with a 35-year-old depressed female client who was recently admitted to the psychiatric facility. Which nursing action is most effective in promoting the development of a therapeutic relationship? A. At your first meeting clearly define the unit's rules and policies B. Obtain client data from her family to use at the first meeting with the client C. Ensure that scheduled appointments begin according to the schedule D. Re-direct all conversations to discussions about feelings of low self-esteem

C. Ensure that scheduled appointments begin according to the schedule

A newly hired male unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAP's. Which intervention should the home health nurse implement to ensure adequate care for all clients? A. Assign the newly hired UAP to clients who require the least complex level of care B. Ask the most experienced UAP on the team to partner with the newly hired UAP C. Evaluate the newly hired UAP's level of competency by observing him deliver care D. Review the UAP's skills checklist and experience wit the person who hired him

C. Evaluate the newly hired UAP's level of competency by observing him deliver care

During the admission interview, the nurse learns that a newly admitted adult client has a six month history of reoccurring somatic pain. Which problem is most important for the nurse to further explore with the client? A. Nausea and vomiting B. Episodes of injury related to falls C. Feelings of depression D. Periods of anxiety and restlessness

C. Feelings of depression

Immediately after an elective cardioversion for rapid supraventricular tachycardia (SVT), a male client who was premedicated with hydromorphone (Dilaudid) and midazolam (Versed) is difficult to arouse. His vital signs are: oxygen saturation 94% while receiving oxygen at 2 L/minute per nasal cannula, heart rate 78 beats/minute, respirations 6 breaths/minute, and blood pressure 102/70. Which intervention should the nurse implement? A. Increase oxygen to 4 L/minute B. Prepare for another cardioversion C. Give IV naloxone (Narcan) D. Infuse normal saline IV bolus

C. Give IV naloxone (Narcan)

The nurse and a social worker are talking when a male client with psychosis angrily shouts at the nurse, "Stop talking about me." The nurse should document the client is exhibiting which symptom? A. Auditory hallucinations B. Visual hallucinations C. Ideas of reference D. Thought broadcasting

C. Ideas of reference

A community health nurse is concerned about the incidence of asthma among preschool aged children in a metropolitan area. Which interventions reflects a primary prevention strategy the nurse might initiate to combat the chronic illness? A. Partner with a major pharmaceutical company to provide nebulizers at a reduced cost to inner-city children B. Refer parents of preschoolers with asthma to a support group sponsored by the American Lung Association C. Inform the city council of the need to strengthen the city's air pollution ordinances D. Offer free asthma screening to children at a health fair sponsored by a local hospital

C. Inform the city council of the need to strengthen the city's air pollution ordinances

Which intervention regarding immediate postoperative care should the nurse plan to include in the preoperative teaching of a client scheduled for an incisional rotator cuff repair? A. Ice will be applied to the incision prior to exercising to help decrease pain B. A cast will be used to hold the joint securely in place until it is healed C. It will be necessary to wear a sling to keep the joint still D. A special machine will be used to keep the joint moving

C. It will be necessary to wear a sling to keep the joint still

The nurse is assessing a 4-year-old with eczema. Her skin is dry and scaly, and the mother reports that she frequently scratches her skin to the point of causing bleeding. Which guideline is indicated for care for this child? A. Apply baby lotion to her skin twice daily B. Allow her to wear only 100% cotton clothing C. Keep her nails trimmed short D. Bathe her daily with bath oil

C. Keep her nails trimmed short

An infant has a medical diagnosis of tracheosophageal fistula (TEF). Which nursing intervention is indicated for this infant prior to surgical repair? A. Administer isotonic enemas as prescribed B. Evaluate the infant's tolerance for small volume of formula C. Maintain suction equipment available at all times D. Prepare the child for a barium enema to correct the condition

C. Maintain suction equipment available at all times

The nurse identifies which recent event as placing a client at high risk for cardiogenic shock? A. Gunshot wounds to the chest and abdomen B. Traumatic amputation of the leg at the groin C. Myocardial infraction in the right ventricle D. Multiple bee stings around the head and neck

C. Myocardial infraction in the right ventricle

To assess for the presence of diaphragmatic breathing, what action should the nurse take? A. Attach an apnea monitor to the chest wall B. Auscultate the lung bases anteriorly C. Observe the movement of the abdomen D. Note any gaps between respirations

C. Observe the movement of the abdomen

A client arrives in the emergency department (ED) with slurred speech and right-sided weakness. Which information is most important? A. Family history of stroke B. Changes in vision C. Onset of symptoms D. Severity of headache

C. Onset of symptoms

Following a devastating hurricane, a client is admitted for dehydration as the result of vomiting and diarrhea that occurred after ingesting contaminated water. The client expresses feelings of fear and anger about the destruction of homes, the loss of property due to the storm, and the looting that occurred following the storm. According to Maslow's hierarchy of need, what priority need should be addressed first? A. Seld-actualization B. Love and belonging C. Physiological needs D. Safety and security

C. Physiological needs

Before placing a client's dentures in the sink for cleansing, what action should the nurse take? A. Fill the sink with half-strength peroxide solution B. Loosen dried secretions with a toothbrush C. Place a washcloth on the bottom of the sink D. Hold the dentures in a stream of running water

C. Place a washcloth on the bottom of the sink

A man who has a known problem with alcohol is accused of stealing from his employer. When he returns home that evening, he accuses his son of stealing from school, and physically abuses the child for what the father describes as the child's dishonest behavior. Which two defense mechanisms are being used by the father? A. Sublimation and displacement B. Denial and sublimation C. Projection and displacement D. Projection and denial

C. Projection and displacement

When checking a third-grader's height and weight, the school notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? A. Report the finding to the parents B. Document findings in the child's school life C. Refer child to the family healthcare provider D. Encourage child to get more sleep

C. Refer child to the family healthcare provider

A female client, newly diagnosed with breast cancer, is scheduled for a mastectomy next week. During the preoperative assessment, she complains that her husband has become withdrawn and complains about her irritability, and frequently crying. How should the nurse respond? A. Explain that a positive attitude helps reduce preoperative complications B. Encourage the spouse to be more supportive at this difficult time C. Refer the couple to a counselor to help them with coping strategies D. Inquire if the couple has met with a minister to discuss their feelings

C. Refer the couple to a counselor to help them with coping strategies

What action should the nurse implement to reduce a client's risk for nosocomial infection? A. Apply a face shield or googles before irrigating an infected wound B. Wear sterile gloves to administer an intravenous medication through a saline loc C. Replace continuous tube feeding bag and tubing at least daily D. Obtain a prescription to irrigate a urinary catheter with sterile saline daily

C. Replace continuous tube feeding bag and tubing at least daily

The nurse administers the opioid antagonist naloxone HCL (Narcan) to a young adult client who overdosed on hydromorphone (Dilaudid). Which assessment data indicates that the naloxone is effective? A. Babinski reflex changes from negative to positive B. Pupil size increases from 4 mm to 6 mm C. Respiration increases from 8/minute to 12/minute D. Blood pressure decrease from 140/94 to 120/78

C. Respiration increases from 8/minute to 12/minute

A client with chronic kidney disease is being discharged with continuous ambulatory peritoneal dialysis (CAPD). What is the priority nursing diagnosis the nurse should use when developing a discharge teaching plan for this client? A. Altered nutriton B. Impaired mobility C. Risk for sepsis D. Risk for injury

C. Risk for sepsis

A client receives a prescription for an intramuscular pain medication. The nurse uses the Z-track method to administer the injection Which rationale supports the nurse's use of this method? A. Prevents injury to the underlying bones, nerves, and blood vessels B. Minimize client's discomfort a the injection site C. Seals needle track to avoid medication leakage through the tissue D. Ensures medication reaches the intramuscular site

C. Seals needle track to avoid medication leakage through the tissue

A client receives a prescription for an intramuscular pain medication. The nurse uses the Z-track method to administer the injection. Which rationale supports the nurse's use of this method? A. Prevents injury to the underlying bones, nerves, and blood vessels B Minimizes client's discomfort at the injection site C. Seals needle track to avoid medication leakage through the tissue D. Ensures medication reaches the intramuscular site

C. Seals needle track to avoid medication leakage through the tissue

The community mental health nurse is planning to visit four clients with schizophrenia. Which client should the nurse see first? A. The young woman who believes she is to blame for her divorce B. The client with a history of substance abuse who is living in a halfway house C. The father who took his children from school because aliens were after them D. The client who needs to be evaluated for medication compliance.

C. The father who took his children from school because aliens were after them

The nurse observes a newly-employed unlicensed assistive personnel (UAP) taking an elderly client's blood pressure. The nurse says "You need to start over. The blood pressure reading you obtained was falsely high for this client." What is the most likely explanation for the erroneous reading? A. The UAP was standing above the sphygmomanometer while taking the reading B. The sphygmomanometer was two feet away from the UAP during the procedure C. The size of the cuff used was too small for this adult client's arm D. The client's arm was elevated above the level of the heart

C. The size of the cuff used was too small for this adult client's arm

A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? A. Lorazepam (Ativan) B. Famotidine (Pepcid) C. Thiamine (Vitamin B1) D. Atenolol (Tenormin)

C. Thiamine (Vitamin B1)

The nurse is preparing a client for a scheduled cesarean section. In which order should the nurse perform these actions? A. Prepping the site with iodophor (Betadine) B. Inserting an indwelling catheter C. Verifying the consent form is signed D. Performing a time-out procedure

C. Verifying the consent form is signed B. Inserting an indwelling catheter A. Prepping the site with iodophor (Betadine) D. Performing a time-out procedure

A client in the intensive care unit is being mechanically ventilated , has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? A. administer PRN dose of lorazepam B. auscultate bilateral breath sounds C. check urinary catheter for obstruction D. review the heart rhythm on cardiac monitor

C. check urinary catheter for obstruction

A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the unlicensed assistive personal (UAP) to implement? A. feed the client the entire meal B. provide with only finer food C. orient the client to location of food on the plate D. ask family member to visit during meal time to assist with feeding

C. orient the client to location of food on the plate

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? A. "I think I am qualified to teach this group." B. "How old do you think I am?" C. "Do you think you can teach it any better?" D. "We need to stay focused on the topic."

D. "We need to stay focused on the topic."

A 60-year-old male client with cancer of the liver has been in a hepatic coma for the past 24 hours. On admission, the client signed a release of information to his family. His oldest son arrives from out of town and asks the nurse how his father is doing. Which response is best for the nurse to provide? A. "I know you are concerned about your father. Would you like to talk about your feelings?" B. The healthcare provider will be here this afternoon and can explain your father's condition to you and the rest of the family." C. "Your father's condition is extremely critical. Would you like me to call the hospital chaplain to talk with you?" D. "Your father has given no response for 24 hours. His condition is extremely critical at this time."

D. "Your father has given no response for 24 hours. His condition is extremely critical at this time."

Assessment of the fetal heart rate is an important finding when caring for a laboring client. Deceleration in fetal heart rate that are of most concern occur at what time during the contraction cycle? A. Before a contraction B. During a contraction C, Between contractions D. After a contraction

D. After a contraction

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN) A. A young adult client who is experiencing fatigue while undergoing a series of external beam radiation treatments for stage 1 cancer. B. A middle-aged male client who has just undergone an excision biopsy and has been told that his tumor appears to be benign C. An adult client in remission after a series of chemotherapy treatments who is receiving intramuscular iron injections for anemia D. An elderly female client with cancer and her children who are trying to decide whether to change to palliative care measures or continue disease control

D. An elderly female client with cancer and her children who are trying to decide whether to change to palliative care measures or continue disease control

The nurse assesses the perineum of a client who is complaining of perineal pain 6 hours after a normal delivery, and finds small perineal (vulvar) hematomas. Based on this assessment finding, which treatment should the nurse implement? A. Cleanse the area with warm water B. Prepare for surgical excision C. Spray topical analgesic to the perineum D. Apply ice packs on the perineum

D. Apply ice packs on the perineum

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A. Auscultate for bowel sounds in all quadrants B. Monitor the client's serum electrolyte levels C. Measure the client's fluid intake and output D. Ask the client about gastrointestinal pain

D. Ask the client about gastrointestinal pain

A relative comes into the emergency department asking for information about a female adult client who was admitted in stable condition following a motor vehicle collision. What action should the triage nurse take? A. Determine what is happening with the client, then provide the relative with her current status B. Inform the relative that legally no information can be provided to him or her C. Ask the relative to wait in the waiting area until the healthcare provider can see him or her D. Ask the client if she would like to talk with the relative, then bring the relative to the bedside

D. Ask the client if she would like to talk with the relative, then bring the relative to the bedside

The nurse plans to administer 5,000 units of heparin, an anticoagulant. Which procedure should the nurse implement when administering this drug? A. Massage injection site after administration to ensure that the solution is dissolved. B. Prior to injecting the solution, check for bleeding by aspirating the plunger C. Administer IM injections into the fatty portion of the upper arm. D. Assess all needle insertion sites daily for hematoma and signs of inflammation

D. Assess all needle insertion sites daily for hematoma and signs of inflammation

The nurse plans to administer 5,00o units of heparin, an anticoagulant. Which procedure should the nurse implement when administering this drug? A. Massage injection site after administration to ensure that the solution is dissolved B. Prior to injecting the solution, check for bleeding by aspirating the plunger C. Administer IM injections into the fatty portion of the upper arm D. Assess all needle insertion sites daily for hematoma and signs of inflammation

D. Assess all needle insertion sites daily for hematoma and signs of inflammation

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the because of a low census in labor and delivery. Which assignment is best for the charge nurse to give this nurse? A. Transfer a client to another hit B. Monitor the central telemetry C. Perform the admission of a new client D. Assis cardiac nurse with their assignments

D. Assis cardiac nurse with their assignments

A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? A. Obtain a pulse oximetry reading and arterial blood gases B. Request a start chest x-ray and prepare medications for an asthmatic episode C. Determine if the child ingested a toxic substance and if vomiting occurred D. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver

D. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver

A client who has had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? A. Obtain a hemoccult of the client's stool B. Palpate the liver and spleen C. Perform a digital rectal exam D. Auscultate all quadrants of the abdomen

D. Auscultate all quadrants of the abdomen

After routine physical examination, the healthcare provider admits a woman with a history of Systemic Lupus Erythematosis (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? A. Dark, rust-colored urine B. Urine output 300 ml/hour C. Joint and muscle aches D. Blood pressure 170/91

D. Blood pressure 170/91

The home health nurse visits a client with heart failure (HF). Assessment findings include: temperature 97.6F, pulse 116 beats/minute, respiratory rate 36 breaths/minute, blood pressure 140/70, pulse oximeter 86% on 2 L/min of oxygen, and crackles are heard throughout the lung fields. Which intervention has the highest priority? A. Start an IV of normal saline (NS) at 100 ml/hr B. Assess for edema and weigh client C. Obtain a prescription for an increased oxygen rate D. Call 911 and prepare the client for transport

D. Call 911 and prepare the client for transport

What is the goal when planning nursing care for a client with edema and leg discoloration secondary to chronic venous insufficiency? A. Adequate oxygenation will be restored B. Client will manifest normal urine output C. Client will demonstrate improved fluid-balance D. Client's skin integrity will remain intact

D. Client's skin integrity will remain intact

The charge nurse in the Labor and Delivery Unit makes assignments for a nurse and unlicensed assistive personnel (UAP). A client in labor is admitted with contractions occurring every 3 to 5 minutes. Which task should be assigned to the UAP? A. Teach patterned breathing B. Apply external fetal monitor C. Measure the fundal height D. Collet a urine specimen

D. Collet a urine specimen

At bedtime, an unlicensed assistive personnel (UAP) is positioning a client with obstructive sleep apnea syndrome (OSAS). The UAP elevates the head of the bed and encourages the client to turn on side. In supervising the UAP, what action should the nurse take? A. After leaving the room, discuss correct positioning with the UAP B. Reposition the client in a supine position with the feet elevated pillows C. Remind the UAP to pad the side rails to reduce risk for injury D. Confirm that the UAP has placed the call bell within reach of the client.

D. Confirm that the UAP has placed the call bell within reach of the client.

Dinoprostone (Prostin E-2) is prescribed for primigravida who had a missed spontaneous abortion. An increase in which finding should the nurse expect? A. Maternal temperature B. Rh antibody production C. Hemoglobin (Hgb) levels D. Contractions of the uterus

D. Contractions of the uterus

A female client with severe renal impairment is receiving enoxaparin (Lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? A. Calcium 9 mg/dl (9 mmol/L SI) B. Hemoglobin 12 grams/dl (120 mmol/L SI) C. Partial thromboplastin time (PTT) 30 seconds D. Creatinine clearance 25 ml/minute

D. Creatinine clearance 25 ml/minute

The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? A. Stares straight ahead without blinking B. Face does not convey any emotion C. Uses a monotone when speaking D. Cries frequently during the interview

D. Cries frequently during the interview

The healthcare provider prescribes Isosorbibide (Isordil) 40 mg every 8 hours for a male client with acute angina pectoris. Which finding should the nurse report to the healthcare provider prior to administering Isordil? A. Serum cholesterol of 200 mg/dl B. Hemoglobin of 14.8 grams/dl C. Takes enteric coated aspirin daily D. Currently takes sildenafil (Viagra)

D. Currently takes sildenafil (Viagra)

A terminally ill client on a palliative care unit has an advanced directive stipulating comfort measure only. The client has not taken oral fluids in the last 36 hours and is not receiving intravenous fluids. The clients blood pressure is 64/38 and urinary output is 50 ml for the last 12 hours. What is the priority nursing intervention? A. Assess for the presence of dependent edema B. Prepare to initiate intravenous fluids C. Gently massage the client's bladder D. Determine the client's level of discomfort

D. Determine the client's level of discomfort

The nurse-manager of a pediatric units needs to assign a room for a 6-month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment is the best for the nurse-manager to make? A. Private room furtherest form the nurses station B. Double room with a 6-month-old on droplet precautions C. Private room with negative air pressure D. Double room with a 4-month-old who has RSV

D. Double room with a 4-month-old who has RSV

The father brings his pre-school-aged son to the rural urgent care clinic because the child fell from a horse earlier today. Which finding indicates to the nurse that further assessment is required for possible abuse or neglect? A. A dislocated shoulder and fractured wrist on X-ray B. Bruises, abrasions, and restricted movement in right shoulder, elbow, and wrist C. Father's presence during the child's assessment and physical examination D. Dry, peeling skin, ridged nails, and significantly underweight

D. Dry, peeling skin, ridged nails, and significantly underweight

The nurse should instruct the parents of an 11-year-old with Type 1 diabetes mellitus to carefully watch their child for symptoms of diabetic ketoacidosis at risk for becoming ketoacidotic? A. While adjusting the amount of the insulin dosage B. When changing to a new brand of insulin C. After skipping two or more meals consecutively D. During the course of an acute illness

D. During the course of an acute illness

The parents of a 6-year-old recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A. Explain that their child is too young to understand risks associated with swimming B. Provide a list of alternative activities that are less likely to cause the child to experience fatigue C. Suggest that the child can be encouraged to participate in a team sport to encourage socialization D. Encourage the parents to allow the child to continue attending swimming lessons with supervision

D. Encourage the parents to allow the child to continue attending swimming lessons with supervision

The healthcare provider prescribes digoxin (Lanoxin) 0.5 mg PO daily for a client with heart failure. When the nurse scans the medication label, "digoxin 0.25 mg/tablet," using an electronic scanner, a "pop-up" window in the electronic medical record indicates "Error in dose." What action should the nurse take? A. Request the pharmacy to deliver the correct dose B. Rescan the medication label until it registers C. Notify the healthcare provider of the error in the data D. Enter the value, 2 tablets, administered

D. Enter the value, 2 tablets, administered

After receiving a prescribed dose of quinapril (Accupril), losartan (Cozaar), and clonidine (Catapres), a female client tells the nurse that she usually takes Accupril at 0800, Cozaar at 1600, and clonidine at 2200 at home. The nurse informs the charge nurse that an error was made during the morning medication administration. What action should the charge nurse implement first? A. Implement orthostatic safety precautions B. Assess the client's level of consciousness C. Increase the client's fluid intake during the day D. Evaluate the clients blood pressure

D. Evaluate the clients blood pressure

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try to convince their mother to reconsider this decision. How should the nurse respond? A. ask the client with her children present if she fully understands the decision she has made B. Discuss success of clinical trials and ask the client to consider participating for one month C. Explain to the family that they must accept their mother's decision D. Explore the client's decision to refuse treatment and offer support

D. Explore the client's decision to refuse treatment and offer support

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Plans to move into the dormitory need to be postponed for at least a semester B. These early signs of an infection may require medical treatment with antibiotics C. These are common side effects of the vaccines and will resolve in a few days D. Immunizations can trigger a relapse of the disease, so get plenty of extra rest

D. Immunizations can trigger a relapse of the disease, so get plenty of extra rest

What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with an HIV infection? A. Increase ability to carry out activities of daily living B. Promote a feeling of general well-being C. Prevent spread of infection to others D. Improve function of the immune system

D. Improve function of the immune system

Which is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with an HIV infection? A. Increase ability to carry out activities of daily living B. Promote a feeling of general well-being C. Prevent spread of infection to others D. Improve function of the immune system

D. Improve function of the immune system

A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a transcutaneous pacemaker, the nurse observes several episodes of the pacemaker's failure to sense. What action should the nurse take? A. Turn off the pacemaker B. Adjust the miliamperes (mA) C. Increase the pacemaker rate D. Increase the sensitively

D. Increase the sensitively

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A. Notify the healthcare provider of the need to reposition the catheter B. Remove the catheter and apply direct pressure for 5 minutes C. Secure the catheter using aseptic techniques D. Initiate intravenous fluids as prescribed

D. Initiate intravenous fluids as prescribed

Two unlicensed assistive personal (UAP) are arguing loudly in the hallway of the extended care facility about who will shower a male resident who defecated in his bed. What action is best for charge nurse to take? A. Shower the client with the help of a practical nurse B. Reassign the clients care to another staff member C. Document the conflict in the employee personnel files D. Instruct both UAP to shower the client immediately

D. Instruct both UAP to shower the client immediately

A client who is experiencing panic attacks receives a prescription for the benzodiazepine alprazolam (Xanax). Which instructions should the nurse provide the client? A. Explain that it may take up to two weeks before the anxiety starts to get better B. Instruct the client to notify the healthcare provider if tremors of the tongue occur C. Discuss the importance of obtaining monthly blood work to assess for toxicity D. Instruct the client on safety issues this medication causes drowsiness

D. Instruct the client on safety issues this medication causes drowsiness

The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (Omnipen-N). What instruction is essential for the nurse to provide this client prior to discharge? A. Inform the client that it is essential to take all of the prescribed ampicillin B. Teach the client how to self-administer epinephrine in case a reaction occurs again C. Tell the client to take medication with food to decrease the possibility of future reactions D. Instruct the client to wear a medic-alert bracelet so penicillin will not be given again

D. Instruct the client to wear a medic-alert bracelet so penicillin will not be given again

A female who was admitted for alcohol detoxification is nauseated and describes feeling like roaches are crawling all over her. She is tremulous, and her blood pressure is 146/92; her pulse rate is 94 beats/minute; and her temperature is 100.8F. Which PRN medication should the nurse administer first? A. Ondansetron (Zofran) B. Acetaminophen (Tylenol) C. Ramiprl (Altace) D. Lorazepam (Ativan)

D. Lorazepam (Ativan)

A client who is admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? A. CT scan of brain B. Electroencephalogram (EEG) C. Synovial fluid analysis D. Lumbar puncture

D. Lumbar puncture

The nurse plans to administer 1 teaspoon of a liquid medication to a toddler. What is the most accurate way to administer the medication? A. Give medication using a medication dropper B. Administer from a clean teaspoon C. Use a medicine cup to measure the dose D. Measure the medication in an oral syringe

D. Measure the medication in an oral syringe

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which intervention is most important for the nurse to include in this client's discharge teaching plan? A. Keep a record of daily urinary output B. Report the onset of scleral jaundice C. Measure the abdominal girth daily D. Monitor for an elevated temperature

D. Monitor for an elevated temperature

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement? A. Send a stool specimen to the lab B. Measure abdominal girth C. Encourage increased fiber in diet D. Monitor mental status

D. Monitor mental status Lactulose is administered to clients with hepatic encephalopathy to lower serum ammonia levels, which should improve the client's mental status

A female client who has been taking diclofenac (Zipsor) for the past month is admitted with right upper quadrant tenderness, jaundice, and flu-like symptoms. She is also complaining of fatigue, diarrhea, and pruritus. Which intervention is most important to include in this client's plan of care? A. Review results of serum protein electrolytes B. Determine frequently of indigestion C. Evaluate intake and output ratios D. Monitor serum bilirubin levels

D. Monitor serum bilirubin levels

The nurse is assessing a 9-year-old boy who is experiencing an acute asthma attack. When auscultating this child's breaths sounds, which finding is the nurse most likely to obtain? A. Diminished breath sounds heard throughout all areas B. Fine crackles upon inspiration C. Louder breath sounds over the lower lung fields D. Musical sounds upon expiration

D. Musical sounds upon expiration

With the client's eyes closed, the nurse places a common object in the client's hand and asks the client to describe the object. The client accurately names the object. How should the nurse document this assessment finding? A. No paraesthesia present B. Short term memory intact C. Active range of motion D. Positive for stereognosis

D. Positive for stereognosis

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take? A. Apply bilateral eye shields to reduce photosensitivity B. Administer an antiemetic to prevent vomiting C. Begin postoperative prophylactic antibiotics D. Report the complaint of eye pain to the surgeon

D. Report the complaint of eye pain to the surgeon

An 18-year-old female client is admitted to the unit after ingesting an overdose of Phenobarbital (Luminal). She is unresponsive and ABG results are: pH 7.18, PaCO2 60 mmHg, and HCO3 26 mEq/L. Which interpretation of the client's ABG results by the nurse is accurate? A. Metabolic acidosis, uncompensated B. Respiratory acidosis, compensated C. Metabolic alkalosis, compensated D. Respiratory acidosis, uncompensated

D. Respiratory acidosis, uncompensated

When preparing to start change-of-shift report, the charge nurse observes an unlicensed assistive personnel (UAP) walking in the hallway with a urine specimen that is not covered. After telling the UAP to cover the specimen, what intervention should the charge nurse implement? A. Ask the nurse educator to review infection control policies with all UAPs. B. Gather input from other staff about the quality of the UAP's performance. C. Direct the UAP to collect all specimens using universal precautions D. Review infection control guidelines with the UAP at the next opportunity

D. Review infection control guidelines with the UAP at the next opportunity

Beginning with the vena cavae, what is the normal sequence of blood circulation through the heart? A. Mitral valve B. Left atrium C. Pulmonary semilunar valve D. Right atrium E. Tricuspid valve F. Aortic semilunar valve G. Left ventricle H. Right ventricle

D. Right atrium E. Tricuspid valve H. Right ventricle C. Pulmonary semilunar valve B. Left atrium A. Mitral valve G. Left ventricle F. Aortic semilunar valve

The unit manager of an acute care unit evaluates the time management skills of the nursing staff and determines that one staff nurse is consistently behind in meeting the needs of assigned clients. What action should the unit manager take? A. Plan to reassign some of the clients to another nurse the nest day B. Determine if the nurse is having personal problems that affect work. C. Request that the nursing supervisor meet with the nurse today D. Schedule a private meeting with the staff nurse as soon as possible

D. Schedule a private meeting with the staff nurse as soon as possible

An adolescent male is transferred from the medical unit to the mental health unit because his condition is stable after taking an assortment of prescription drugs. Based on the admission interview, the nurse determines that the client is still having suicidal ideations. What intervention is most important for the nurse to implement? A. Try to determine what life event precipitated the suicide attempt B. Place the client in lock-up until the psychiatrist releases him C. Reassure the client that he is in a safe place D. Search the client's belongings for potential weapons

D. Search the client's belongings for potential weapons

A female client who had a total thyroidectomy several weeks ago is admitted with myxedema coma. Which finding indicates that the client has been noncompliant with her postoperative treatment plan? A. Systolic blood pressure consistently greater than 160 B. Suppressed levels of thyroid stimulating hormone (TSH) C. Telemetry reveals atrial fibrillation D. Serum T3 and T4 levels below normal

D. Serum T3 and T4 levels below normal

A female client receives a prescription for alendronate sodium (Fosamx) to treat her newly diagnosed osteoporosis. What instruction should the nurse include in the client's teaching plan? A. Eat within 30 minutes of taking the medication B. Ingest an antacid 30 minutes prior to taking the tablet C. Consume a light snack with the medication D. Take on an empty stomach with a full glass of water

D. Take on an empty stomach with a full glass of water

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first? A. Provide the client with a PRN antianxiety medication and allow privacy for her to grieve B. instruct the UAP to notify the client's spiritual advisor of her need for counseling C. Ask another nurse to finish giving medications and attend to the client immediately D. Tell the client that the nurse will be back to talk to her after medications are given

D. Tell the client that the nurse will be back to talk to her after medications are given

An emergency department nurse is giving discharge instructions to the wife of a young adult male client who sustained a concussion after a fall. The nurse should provide the wife with what instruction as part of the discharge teaching plan? A. Encourage the wife to bring her husband back to the emergency department if he experiences headaches within the next 24 hours B. Teach the wife how to complete a Glasgow Scale (GCS) to do at home C. Provide written instructions on determining pupil constriction D. Tell the wife to bring her husband back to the emergency department if he has projectile vomiting or an unsteady gait

D. Tell the wife to bring her husband back to the emergency department if he has projectile vomiting or an unsteady gait

A nurse is caring for an elderly client who recently attempted suicide with a overdose of sedatives. Which conclusion regarding this client's achievement of normal development is accurate? A. Suicide attempts that occur in the elderly population are most likely due to declining physical health B. The client was unsuccessful in resolving Trust vs. Mistrust issues, resulting in anger turned inward C. Role confusion often occurs in the elderly due to various levels of dementia, which explains suicidal tenderness D. The adult who is unfulfilled at an advanced age fails to achieve ego integrity, and instead experiences despair

D. The adult who is unfulfilled at an advanced age fails to achieve ego integrity, and instead experiences despair

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? A. The client complains of pain at the insertion site B. The client's chest x-ray indicates decreased pleural effusion C. The client's arterial blood gases are pH 7.35; PaO2 85; PaCO2 35; HCO3 26 D. The client has asymmetrical chest wall expansion

D. The client has asymmetrical chest wall expansion

The nurse in the outpatient department is caring for a client who had a right femoral cardiac catheterization two hours ago. What assessment finding requires immediate intervention? A. The client's right foot is warm to touch B. The client's blood pressure is 110/70 and pulse 88 C. The client's pulse oximeter reading is 98% D. The client wants assistance walking to the bathroom

D. The client wants assistance walking to the bathroom

A frail, elderly female with rheumatoid arthritis (RA) complains to the nurse that the weight of the sheets on her legs hurts all the time. Which action should the nurse implement? A. Soak her hands in warm water when resting B. Administer an analgesic at the hour of sleep C. Provide a soft blanket for covering the client D. Use a bed cradle to keep linens off her legs

D. Use a bed cradle to keep linens off her legs

After a 92-year-old client fractured a hip trying to get out of bed, a nurse is accused of failing to notify the healthcare provider that the client was disoriented. In determining whether the nurse is guilty, a jury would consider which standard? A. What the nurse was taught in school about similar client care situations B. What an experienced lawyer would advise to be done in a similar situation C. What a well-educated healthcare consumer would expect in the same situation D. What a reasonable and prudent nurse would have done in the same situation

D. What a reasonable and prudent nurse would have done in the same situation

The nurse is completing a neurological assessment. What observation indicates an abnormal pupil response? A. When shinning the light into the eye, the pupil contracts briskly B. The optic disc appears edematous and engorged C. As the nurse's finger is brought in closer to the eye, the pupils contract D. When shining the light into the right eye, the left pupil does not constrict

D. When shining the light into the right eye, the left pupil does not constrict

An adult is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? A. rebound abdominal tenderness B. diminished bilateral breath sounds C. rub pain with deep inspiration D. nausea with projectile vomiting

D. nausea with projectile vomiting