The Point-LWW MOCK NCLEX

A client is being discharged home with a diagnosis of hypertrophic cardiomyopathy (HCM). Which statement by the client best demonstrates an understanding of this disease process?

"Since this is a hereditary disorder, my family members should probably be evaluated for similar symptoms."

A client sustained burns to the entire back and left arm. Using the Rule of Nines, calculate the percentage of burns on this client's body.

27%

A 45-year-old client receiving radiation therapy for thyroid cancer reports mouth and throat pain. While inspecting the mouth and throat, the nurse notices white patches and ulcerations in the oral mucosa. What do these findings suggest?

Candidiasis

When collecting data on a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation?

Caput succedaneum

The emergency department nurse obtains laboratory test results for a newly admitted client. Which result should she report to the physician immediately?

Cardiac troponin I level of 3.0 mcg/L

The nurse is caring for a terminally ill client with cancer who is receiving hospice services with an advance directive. Which nursing action is a priority?

Care for elimination needs.

A client suspected of having a pulmonary embolus is scheduled for a lung scan. What is the most important action for the nurse prior to the procedure?

Check all allergies of the client.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?

Decrease environmental stimulation.

Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which concerns?

Headache, blurred vision, and facial and extremity swelling

Which of the following nutritional deficiencies may delay wound healing?

Lack of vitamin C

Which of the following is an appropriate nursing diagnosis for a client with renal calculi?

Risk for infection

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?

a 30-year-old client with schizophrenia taking chlorpromazine

Which client is at the greatest risk for developing sensory overload?

an 80-year-old client in the intensive care unit (ICU)

A client arrives in the emergency department with a nosebleed. What is the first action by the nurse?

pinch the nares together at the bridge of the nose

A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she:

wear a supportive, well-fitting brassiere.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. The client inquires about Cheyne-Stokes respirations. What information would the nurse include in her explanation?

"They are progressively deeper breaths followed by shallower breaths with apneic periods."

A client with renal insufficiency is admitted with a diagnosis of pneumonia, episodes of hypotension, and is receiving intravenous antibiotics. Which laboratory value should the nurse monitor?

blood urea nitrogen (BUN) and creatinine levels

A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to:

breast-feed every 1½ to 3 hours.

The nurse is preparing to administer an immunization to a 2-month-old child. The child's parent states, "I am going to put off the immunizations because I hate to see my child hurt." Which response by the nurse is most appropriate?

"Although your baby will feel discomfort now, it will be short lived."

The nurse is caring for a client on the orthopedic unit. When preparing the client for discharge, which instructions should the nurse reinforce after surgical repair of a hip fracture?

"Do not flex the hip more than 90°, do not cross your legs, and get help putting on your shoes."

Which statement by the client best indicates an understanding on how to prevent complications while taking warfarin?

"I should use a soft toothbrush."

A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond?

"The goal is teaching the client how to perform self-care activities."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. The client has questions about the paralysis. What information will the nurse tell the client about the paralysis?

"The paralysis caused by this disease is temporary."

Preoperatively, the health care practitioner orders antiembolism stockings for a client scheduled for open heart surgery. The client asks the nurse what is the purpose of antiembolism stockings. How does the nurse appropriately responds?

"The stockings will reduce or prevent edema in your legs and feet."

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal the infant's hematocrit is 24%. Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

"What's the infant's usual daily diet?"

The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use?

25G, 5/8" needle

A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?

Alteration in the size, shape, and organization of differentiated cells

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

When caring for a toddler, the nurse should understand that a child in this age-group works to achieve which developmental task?

Autonomy

A client who has had a pacemaker inserted is ready for discharge. What information should the nurse reinforce in the discharge instructions to the client?

Avoid exposure to magnetic resonance imaging (MRI) equipment.

Which intervention by the nurse would be most helpful when discussing hypospadias with the parents of an infant with this defect?

Be there to listen to the parents' concerns.

A client is placed on oxygen therapy via a nasal cannula. Which should be the first action by the nurse?

Confirm the health care provider's order for oxygen.

The nurse is caring for a child who has recently been diagnosed with a cardiovascular disorder. The child's parents do not seem to be accepting of the diagnosis and the changes the diagnosis will make in their lives. What initial action by the nurse will be most therapeutic?

Encourage the parents to discuss their feelings about the loss of their child's health.

A 2-year-old child comes to the emergency department with inspiratory stridor and a barking cough. What is the highest priority action by the nurse?

Establish and maintain the airway.

A dystonic reaction can be caused by which medication?

Haloperidol

Which medication is considered safe during pregnancy?

Insulin

The nurse is caring for a preschool aged child who has been prescribed a preoperative intramuscular (IM) injection at 07:00. To elicit the child's cooperation in administering this medication, the nurse should use which approach?

Let the preschooler choose which leg to use for the injection.

A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the nurse expects the health care practitioner to most likely prescribe which drug?

Lorazepam

The nurse cares for a client who has been performing respiratory exercises. Which action should the nurse take to determine the effectiveness of the exercises?

Obtain a pulse oximetry reading.

Which finding should alert a nurse to a potential complication in a client with a cast following fracture of the radius?

Pain occurs over a bony prominence.

A nurse is caring for a client admitted with a diagnosis of multiple myeloma. Which nursing intervention is most appropriate for this client?

Prevent bone injury.

The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority?

Provide for the client's safety needs.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse assists with formulating a nursing diagnosis of Risk for injury. Which "related- to" phrase is appropriate for the nurse to add to complete the nursing diagnosis statement?

Related to impaired balance

A 2-year-old child is diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV). The client has an 8-year-old sibling. Which statement is correct?

The siblings should be separated to prevent the spread of the infection.

A nurse is preparing a client for a stress test. Which is an appropriate nursing intervention?

Verify that a consent form has been signed.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first?

Verify the physician's order.

A nurse reviews the laboratory results for a client reporting right lower quadrant abdominal pain. Which laboratory finding should the nurse report to the health care provider immediately?

white blood cell (WBC) count of 22.8/mm

A client comes to the clinic for right shoulder pain. The nurse observes bruises resembling fingerprints on several areas of the right arm and bruising on the back. The client has a history of similar injuries in the past. What questions would be important for the nurse to ask? Select all that apply.

"Are you in a relationship that makes you afraid or unsafe?" "People in relationships argue. What happens when you and your partner argue?" "If you are in danger now, would you like help in locating a shelter?"

The parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate?

"At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."

During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?

"I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

The nurse is caring for a client with new-onset type 2 diabetes mellitus. Which statement by the client indicates that additional education regarding the relationship between diabetes and exercise is required?

"I should wait to eat until after I have finished exercising."

When determining a client's knowledge of symptoms to report during pregnancy, which statements would indicate to the nurse that the client understands the information given? Select all that apply.

"If I have blurred or double vision, I should call the clinic immediately." "If it takes longer than two hours for the baby to move ten times, I should call my doctor."

A client asks the nurse why he needs to apply a cold pack on a sprained ankle. Which response would be most appropriate?

"It constricts local blood vessels and decreases swelling."

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated?

"It's common for you to have a full bladder even though you can't sense it."

After being admitted to the hospital with sickle cell crisis, a client asks a nurse how he can prevent another crisis. Which response by the nurse is best?

"Make sure that you drink plenty of fluids."

After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that education needs to be reinforced when which question is asked?

"So, hypothyroidism can be treated by exposing our baby to a special light, right?"

A nurse is reviewing infection-control measures with a group of unlicensed assistive personnel (UAP). Which statement made by one of the group members indicates learning goals have been met?

"Standard precautions should be used when performing client care."

A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's caregiver tells the nurse about feelings of guilt. What would be an appropriate response by the nurse?

"Tell me more about your feelings."

The nurse is gathering data from a newly admitted client. The client states, "I have been taking my high blood pressure medicine, but not like I am prescribed to take it." Which response is appropriate for the nurse to make in response to this information?

"Tell me what you mean by not taking the medicine as prescribed."

A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, "When is the infectious period?" What statement made by the nurse is most accurate?

"The client is infectious 1-2 days before the rash appears and until the blisters are crusted."

When explaining the hypoxic drive to the client, which statement by the nurse is best?

"This is when you only breathe when your oxygen levels dip below a certain point."

The nurse is reinforcing education for a client diagnosed with genital herpes. Which educational instructions should the nurse include to best prevent spread of the disease? Select all that apply.

"Use a separate towel to pat lesions dry and another to dry other parts of the body." "It is important to inform your partner of the disease."

A client and spouse are seeking treatment for infertility after having difficulty becoming pregnant. Which statement made by the client does the nurse determine is causing the most "stressful aspect of treatment"?

"We have to schedule sexual intercourse with our busy lives."

A homosexual client tells the nurse that "my family is not supportive." What is the best response by the nurse?

"What do you mean by not supportive?"

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal a hematocrit of 24% (0.24). Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

"What's the infant's usual daily diet?"

An older adult client fractured a hip after a fall in the home and surgical correction is not an option due to comorbid factors. The client states to the nurse, "How will I ever get better? Which response by the nurse is best?

"What's your biggest concern right now?"

The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate?

"While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery."

Which instruction should the nurse include in teaching about diet to parents of a preschool-age child who's prescribed corticosteroids?

"You need to make sure your child consumes a low-sodium diet."

A client is prescribed haloperidol. When reinforcing the teaching plan about the drug, which instruction would the nurse emphasize?

"You should report feelings of restlessness or agitation at once."

An older adult client's husband tells the nurse he's concerned because his wife insists on talking about events that happened to her years ago. The nurse finds the client alert, oriented, and answering questions appropriately. Which statement made to the husband is correct?

"Your wife is reviewing her life."

A child is admitted with a diagnosis of croup. Which characteristic signs would the nurse monitor in this client? Select all that apply.

"barking" cough severe respiratory distress increased heart rate

A client is ordered a dose of epoetin alfa to treat anemia related to chemotherapy. The recommended dose is 150 units/kg. The client weighs 60 kg. The vial is labeled 10,000 units/mL. How many milliliters of epoetin alfa should the nurse administer? Record your answer using one decimal place.

0.9

A health care provider's order reads: amoxicillin 500 mg capsules × 2 PO now, followed by 500 mg PO every 6 hours. How many grams of amoxicillin will the nurse administer as the initial dose? Record your answer as a whole number.

1

The licensed practical nurse is collaborating with the registered nurse validating a test dose of mannitol solution IV for a client with marked oliguria. The ordered test dose is 0.2 g/kg of 15% mannitol solution IV. The client weighs 132 lb (59.8 kg). How many grams should the nurse administer? Record your answer as a whole number.

12

The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

38.9° C

A client undergoing treatment for an anxiety disorder is being cared for by a nursing student. The nursing faculty asks the student When is such a disorder considered chronic and generalized? What timeframe does the student provide about the existence of the client's "excessive anxiety and worry about two or more life circumstances"?

6 months

A client is prescribed an I.V. solution of 1,000 mL to be infused from 0800 to 2000. The nurse will use an infusion pump that delivers in milliliters per hour. At what rate should the nurse set the pump to deliver the solution? Record your answer using a whole number.

83

The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of?

A client outcome

Which of the following effects is an advantage of the antipsychotic medication risperidone?

A lower incidence of extrapyramidal effects

Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?

Acute pain related to sickle cell crisis

For which rationale, when administering a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe?

Adding air prevents the drug from flowing back into the needle track.

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority?

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

A client with chronic renal failure must restrict her fluid intake to 500 ml daily. Despite having reached the limit, the client is insisting that she have more fluid. Which intervention by a nurse is appropriate?

Allow her to have a piece of hard candy.

Which action should the nurse include in the plan of care for a 2-month-old infant with heart failure?

Allow the infant to rest before feeding.

The nurse is observing a new mother interact with her baby for the first time approximately 1 hour after the baby's birth. Upon receiving the baby, the mother begins to undress her baby. Which of the following should the nurse do?

Anticipate and support the behavior as a normal part of bonding.

Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately?

Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute

The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

A nurse is monitoring a client who has just returned from a vein ligation and stripping. Which is an appropriate nursing intervention?

Apply bilateral compression stockings.

A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the child waits to be seen by the primary health care provider, what is the priority nursing action?

Apply ice to the injured shoulder.

The nurse intervenes in the care of a client who is experiencing a postoperative wound evisceration. Which action should the nurse perform first?

Apply sterile saline moistened gauze over the area.

A nurse observes a coworker administering a medication several hours after it had been scheduled. When confronted, the coworker simply makes a dismissive joke and then charts the medication as given at the scheduled time. What should the witnessing nurse do? Place the actions in chronologic sequence. All options must be used.

Approach the coworker in a calm and professional manner. Request a private meeting to discuss the incident. Express concern and clearly inform the nurse the behavior is unethical. Encourage the nurse to take responsibility for these actions. Report the incident to the nurse-manager if resistance is noted.

A client brings her food journal containing her dietary intake for the past 3 days to the diabetic clinic. A nurse notes that despite dietary teaching about carbohydrate intake, the client consumed 3 servings of bread each day. What should the nurse do with this information?

Ask the diabetes educator to review with the client ways to decrease carbohydrate intake.

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?

Ask to speak to the parents privately without the grandmother present.

During the first 24 hours after a client is diagnosed with addisonian crisis, which task should the nurse perform frequently?

Assess vital signs.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.

A nurse is assigned the care of an 87-year-old client with multiple ulcerations, which require dressing changes. The nurse is also assigned the care of a 50-year-old client, who is ordered to receive 2 units of packed red blood cells. Which task can the nurse delegate to the nursing assistant?

Assisting the clients with bathing

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

Asymmetry

The nurse is reinforcing education regarding insulin injections with an 11-year old child with diabetes Type I. Which guideline is appropriate to follow?

At age 11, the child should be old enough to give injections independantly.

A 2-year-old returns from surgery after a bowel resection as a result of Hirschsprung disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority?

Auscultate lung sounds.

For a client with an endotracheal (ET) tube, which nursing action is most essential?

Auscultating the lungs for bilateral breath sounds

A child with a Wilms tumor has had surgery to remove a kidney and has received chemotherapy. The nurse should include which instructions at discharge?

Avoid contact sports.

The nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Avoid internal rotation of the affected leg.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?

Avoiding using soap on the irradiated areas

The nurse is identifying a unit of packed red blood cells with a coworker before administration. The client's blood type is AB negative. Which blood type can safely be administered to this client?

B negative

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans, hamburger, and milk

The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor. What information should the nurse provide to the parents? Select all that apply.

Be sure to keep the monitor on a flat surface away from other appliances. Develop a plan in case of a power failure. The parents should take a CPR course.

Which statement accurately describes estrogen and progesterone levels during the 16th week of pregnancy?

Both estrogen and progesterone levels are rising.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

Bulb syringe with tubing

A client who has experienced a stroke is unable to move without help. Which intervention should the nurse perform to reduce this client's risk for developing a common complication of immobility?

Change the client's position every 1 to 2 hours.

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." What about the client's ability to think is being assessed by the health care practitioner?

Client's ability to think abstractly

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions?

Consider all body substances potentially infectious.

A client tells a nurse that her ileoconduit appliance won't adhere to her skin. The nurse inspects the site and notes that the area around the stoma is red, moist, and tender to touch. How should the nurse intervene?

Consult the wound-ostomy nurse.

The nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action would be most appropriate for the nurse to take?

Consulting with the social worker to help the family find appropriate resources

A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply.

Contact Standard

A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse would interpret which finding as a positive response to this drug?

Decreased urine output

A child, age 4, with a recent history of nausea, vomiting, and diarrhea is admitted to the pediatric unit with a diagnosis of gastroenteritis. During data collection, the nurse detects tenting. This finding supports a nursing diagnosis of:

Deficient fluid volume related to dehydration.

A client who speaks and understands minimal English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

Demonstrating the procedure and having the client perform a return demonstration

A nurse is reinforcing education for a client on how to perform tracheostomy care. What is the most important principle of client education that the nurse needs to utilize?

Determine the client's readiness to learn new information.

A client who's admitted with new-onset diabetes mellitus is prescribed an 1,800-calorie diabetic diet. His insulin orders include regular insulin coverage using a sliding scale, and long-acting insulin every morning just before breakfast. Why was the sliding scale insulin coverage prescribed?

Directs the nurse to administer regular insulin doses according to finger-stick glucose levels without notifying the physician

When instructing an 8-year-old child about obtaining a clean-catch urine specimen, which information should be included by the nurse?

Discard the first voided specimen of the day.

An adult client scheduled for surgery chooses to waive the right to informed consent. What should the nurse do?

Document that the client waived the right in the medical record.

One day after a client gives birth, the nurse performs a postpartum assessment. The nurse finds a moderate amount of lochia rubra on the client's perineal pad. Which action should the nurse?

Document this as a normal finding

A nurse is reinforcing education to a client with prostatitis who is receiving co-trimoxazole double strength. Which education is appropriate for this client?

Drink six to eight glasses of fluid daily while taking this medication.

Which nursing action takes priority when admitting a client with right lower lobe pneumonia?

Elevate the head of the bed 45 to 90 degrees.

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take?

Encourage the client to breast feed the baby more frequently and regularly.

A nurse caring for a client during the first 24 hours following delivery notes normal lochia. Which of the following should the nurse include in the care of this client?

Encourage the client to increase fluid intake.

The nurse finds an adult client collapsed in the hallway. Which action should the nurse take first when arriving to assist this client?

Establish unresponsiveness.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder-retraining program?

Evaluate present elimination patterns.

After placing a client in full leather restraints, how often should the nurse check the client's circulation?

Every 15 minutes

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?

Explain that these are expected problems for the latter stages of pregnancy.

A nurse is caring for an older adult client with chronic open-angle glaucoma. After the nurse administers pilocarpine, the client reports blurred vision. Which nursing action is most appropriate?

Explain that this is an expected side effect.

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first?

Explore her own personal beliefs and feelings about contraception.

The client is receiving an infusion of cytarabine through a peripheral IV catheter when he reports burning at the insertion site. The nurse notes no blood return from the catheter, but she sees redness at the IV site. The client is most likely experiencing which complication?

Extravasation

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?

Fetal heart rate variability within an acceptable range

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which data collection findings are consistent with this syndrome?

Fever, decreased level of consciousness (LOC), and impaired liver function

A client undergoing prenatal blood testing is found to be positive for human immunodeficiency virus (HIV). Which action would be most appropriate for the nurse to do?

Follow facility policy for documenting and communicating HIV status.

A client is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture?

Fracture of the distal radius

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?

Make arrangements for the client to receive information about advance directives.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?

Monitor the client's weight every day.

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take?

Notify the nursing supervisor and approach the individual.

While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?

Notify the physician upon arrival at the operating room.

An adult client was admitted with myasthenia gravis. While reviewing the client's chart, the licensed practical nurse (LPN)/licensed vocational nurse (LVN) noticed the medication administration record (MAR). Based on the information, what should the nurse do next?

Notify the registered nurse and question the morphine sulfate.

A child is diagnosed with diabetes insipidus has developed a viral illness including congestion, nausea, and vomiting. What instructions should the nurse reinforce?

Obtain an alternate route for desmopressin acetate administration.

When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program?

Obtain peer educators to provide information about AIDS.

A client with chronic anxiety disorder reports chest pain. Which nursing intervention is most appropriate?

Obtain vital signs.

A client seeks care for low back pain of 2 weeks' duration. Which data collection finding suggests a herniated intervertebral disk?

Pain radiating down the posterior thigh

Which nursing intervention is most appropriate for a child with cystic fibrosis who is having difficulty clearing secretions?

Perform chest physiotherapy four times per day.

Which steps should the nurse follow to insert a straight urinary catheter?

Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

A client who's being admitted to labor and delivery has the following data collection findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which would be the priority at this time?

Preparing for immediate delivery

The nurse is reviewing the chart of a client receiving chemotherapy for lung cancer. She is alarmed to note that the client has developed thrombocytopenia. Which precaution should the nurse implement to ensure the clients safety?

Provide the client with an electric razor.

A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, "No." What should the nurse do next?

Provide the client with information about an advance directive.

A woman who is 10 weeks pregnant tells the nurse that she is worried about her fatigue and frequent urination. Which nursing intervention should the nurse utilize?

Recognize these as normal early pregnancy signs and symptoms

A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?

Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.

A nurse is caring for a confused client with a fractured hip who is trying to get out of bed. Which action should the nurse take first?

Reorient the client to the surroundings.

The licensed practical nurse (LPN) is assigned to care for a 4-year-old child who had a Harrington rod inserted the day before and notices the client is receiving antibiotics by a syringe pump. The nurse is IV certified, but uncomfortable because they are unfamiliar with the equipment. What would be the best course of action?

Request in-service education for use of the syringe pump.

A nurse is investigating the smell of smoke in the hallway of a long-term care unit. On entering a client's room, the nurse finds the wastebasket on fire. The nurse takes immediate action. Place the nurse's actions in proper order from first to last. All options must be used.

Rescue the client. Trigger the alarm. Confine the fire. Extinguish the fire.

The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.

Restrict exercise.

The nurse has an order to administer an intramuscular (I.M.) injection using the Z-track technique. When carrying out this order, what nursing intervention should the nurse implement?

Simultaneously withdraw the needle and release the skin.

A client with schizophrenia becomes agitated and confronts the nurse with clenched fists. Which is the priority action of the nurse?

Speak to the client in a quiet voice and offer the client medication to help calm down.

A client was admitted with a brain tumor. Which vital signs would the nurse expect to notice?

T, 99° F (37.2° C); P, 52; R, 12; BP, 176/86

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?

The client entered a clinical trial through the National Cancer Institute.

A client diagnosed with a pleural effusion has been on supplemental oxygen for 24 hours and is still having dyspnea with decreased breath sounds on the left. The client's condition is worsening. Which procedure will the nurse prepare the client for?

The client is incompetent. Compelling reasons exist to overrule the client's wishes.

The nurse is reinforcing the correct use of crutches to a client in the emergency. Which should the nurse include?

The crutches should end 2 in (5 cm) below the axilla.

The newly hired graduate nurse asks the nurse preceptor what is the only advantage of using a floor stock system. Which rationale does the preceptor give the graduate nurse?

The nurse can implement medication orders quickly.

The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education?

The nurse dons a surgical isolation mask when entering the client's room.

A nursing faculty is preparing a lecture on the foundation of nursing knowledge. Which framework for nursing education and clinical practice would faculty include in the lecture?

Theoretical and conceptual models

A client with acne vulgaris is seeking treatment. The nurse will reinforce education on nightly apply of which medication?

Tretinoin

A client, age 36, with schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?

Trust versus mistrust

Which statement by the nurse would be the best response to parents who want to know the first indication that their child's acute glomerulonephritis is improving?

Urine output will increase.

The parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment?

Using gestures to express desires

A nurse reviews a client's medical record and notes that a physician ordered an indwelling urinary catheter due to client's urine retention. Which action should the nurse perform first?

Verify the client's identity.

A client with hypothyroidism is prescribed levothyroxine 0.05 mg by mouth daily before breakfast. As the nurse gives the client the medication, the client states, "What dose am I getting? I've been taking 0.15 mg every day for years." Which action by the nurse is most appropriate?

Verify the dose against the health care provider's prescription in the client's medical record.

A client with advanced breast cancer is prescribed tamoxifen. When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?

Vision changes

A nurse is reinforcing education for a client with allergies about anaphylaxis. What should the nurse be sure to include in this discussion?

Wear a medical identification bracelet.

A client has a tumor of the posterior pituitary gland. The nurse assisting with the development of the plan of care should include which nursing interventions? (Select all that apply.)

Weigh the client daily. Measure urine specific gravity. Monitor intake and output.

A pregnant client at 26 weeks' gestation undergoes a glucose tolerance test. The nurse identifies the need for further action based on which results?

a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test

A nurse is taking care of four clients. Which client should the nurse see first?

a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome

A nurse reviews the health history of four clients. Which client is at greatest risk for the development of colorectal cancer?

a 52-year-old client with a family history of polyposis

Which of the following clients should the nurse question about their signed consent form for surgery?

a 54-year-old client with a fractured femur committed to a mental health unit

A 5-year-old child sustained third-degree burns to the right upper extremity after tipping over a frying pan. Which skin structures would the nurse include when explaining a third-degree burn to the child's parent?

all skin layers and nerve endings

The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to:

allow the toddler to bathe as much of himself as he can with supervision.

A 4-year-old girl is admitted to the hospital to rule out a diagnosis of leukemia. Which would be the best room assignment for the nurse to select for this child?

alone in a private room

A client who is hospitalized with scleroderma signs a document that provides instructions concerning the provision of care if the client is unable to make their own treatment decisions. The document is known as:

an advance directive

The nurse is observing a client's breathing. Which finding should the nurse prioritize for follow up?

an audible high-pitched sound upon inspiration

A pregnant client is screened for tuberculosis during at the first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. The nurse determines that the result is positive based on which finding?

an indurated wheal larger than 10 mm in diameter appearing in 48 to 72 hours

When observing a client in the emergency department after a head trauma, the nurse knows to monitor the client for a lucid interval. Which statement best describes a lucid interval?

an interval when the client is oriented but then becomes somnolent

The nurse is reinforcing education to the parents of a child with leukemia about the three main consequences. What should the nurse inform the parents they should monitor for?

anemia, infection, and bleeding tendencies

A nurse working in the postanesthesia care unit is caring for multiple postoperative clients . Which task chould be delegated to unlicensed assistive personnel (UAP)?

apply sequential compression device to the client's leg

The nurse is caring for a client who has been diagnosed with narcolepsy. Which actions may assist the client in managing this condition? Select all that apply.

avoid smoking follow a regular schedule for sleep and rest limit caffeine intake

A family meeting is held with a client who uses alcohol. While listening to the family, which unhealthy communication pattern might be identified?

avoidance of issues that cause conflict

Echocardiography reveals vegetation on a client's heart valves. The nurse knows that this finding indicates:

bacterial invasion.

A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

bilateral hearing loss.

A client comes to the clinic with back pain that has been unrelieved by continuous ibuprofen use over the past several days. Current prescription medications include captopril and hydrochlorothiazide. Which laboratory value should the nurse report?

blood urea nitrogen (BUN) of 26 mg/dL and serum creatinine of 2.35 mg/dL

A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task would be appropriate for the LPN to delegate to the CNA?

bottle-feeding a 24-hour-old neonate

A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis symptoms. Which potential complication requires frequent assessment?

bowel perforation

The nurse receives a call from the laboratory with lab values. Which lab value represents the highest priority for the nurse?

calcium, total 32 mg/dL (8 mmol/L)

The nurse is gathering data from a client who has the potential to have impaired neurovascular function from a cast application. What data are important for the nurse to gather to make sure there is not neurovascular impairment?

capillary refill, movement, pulses, warmth

A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition? Cherry-red skin indicates exposure to high levels of carbon monoxide.

carbon monoxide poisoning

The nurse is gathering data from a child suspected of ingesting paint chips from an old home. Which system does the nurse closely monitor for serious effects?

central nervous system (CNS)

An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this teen's fluid balance to decrease the risk of what complication?

cerebral edema

In which group is it most important for the client to understand the importance of an annual Papanicolaou (Pap) test?

clients infected with the human papillomavirus (HPV)

When observing a neonate with congenital hypothyroidism, the nurse would be alert for which complication as the most serious consequence of this condition?

delayed central nervous system development

A client experienced a perinatal loss 3 days ago. The nurse is concerned that the client may be experiencing dysfunctional grieving based on which finding?

denial of the death

A nurse is providing care for a pregnant client in her second trimester. A 1-hour oral glucose tolerance test results show that the client has a blood glucose level of 160 mg/dL. Which intervention would the nurse anticipate as being included in the client's multidisciplinary plan of care?

dietary management

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:

dislodge the autografts.

The nurse assists in developing a list of nursing diagnoses for a client. This list should include:

factors influencing the client's problem.

The nurse is caring for a client with hypothyroidism. Which client data would the nurse expect to collect?

fatigue, cold intolerance, weight gain, and constipation

A 1-month-old infant is admitted to the pediatric unit and diagnosed with bacterial meningitis. Which findings by the nurse support the diagnosis?

fever, change in feeding pattern, vomiting, or diarrhea

A nurse is caring for a client with lower back pain who is scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position?

head of the bed elevated 45 degrees

When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom?

headache

The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

identify anxiety-causing situations.

According to Erikson, an adolescent who's suffering from gender dysphoria can't progress through which developmental task?

identity versus role confusion

The nurse is caring for a client with acute renal failure. Rank in chronological order the phases of acute renal failure. Use all the options.

initial insult oliguric phase diuretic phase recovery phase

A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered?

lateral

The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:

place the client in high Fowler's position.

A client diagnosed with major depression states, "Everything is my fault, and I would be better off dead." Which priority intervention would the nurse implement?

place the client on suicide precautions

When collecting data on a neonate for signs of diabetes insipidus, a nurse should recognize which symptom as a sign of this disorder?

polyuria and polydipsia

Which nursing intervention should the nurse give highest priority to when caring for an unconscious client?

positioning the client with the head of bed at a 15 to 30 degree angle

A client who is 27 weeks' pregnant arrives at the health care provider's office reporting fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. About which condition does the nurse anticipate reinforcing education?

pyelonephritis

A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child?

reading

The nurse is caring for a client with esophageal varices. What is a priority intervention when caring for this client?

recognizing hemorrhage

A client with peptic ulcer disease is receiving propantheline bromide. Which finding indicates to the nurse that the medication has been effective?

reduced abdominal pain

The nurse is assisting with the development of a plan of care for a client with illness anxiety disorder. What would be an appropriate goal for this client?

relieving the fear of serious illness

A nurse is assisting with the development of a plan of care for a client who has undergone electroconvulsive therapy (ECT). Which intervention would most likely be included?

reorienting the client to time and place

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:

risk manager.

Which clinical manifestations should a nurse expect to see in a child in stage V of Reye syndrome?

seizures, flaccidity, and respiratory arrest

A client with a narcissistic personality disorder states to the nurse, "I don't care what you say. I know much more about nursing than you ever will!" What nursing intervention is essential at this time?

set limits for socially acceptable client behavior

A nurse is caring for a client newly diagnosed with Human Immunodeficiency Virus (HIV). Which action by the nurse violates the client's confidentiality?

sharing the client's information with the clergy who is visiting with the client

A client informs the nurse that the client has difficulty sleeping. About which conditions does the nurse question the client to determine factors that inhibit adequate sleep patterns? Select all that apply.

shift work sleep apnea caffeine intake in the evening Excessive worry or anxiety

A confused client is brought to the emergency room. The client's has a heart rate of 108/minute and blood pressure 102/68 mm Hg. The family states the client has been taking lithium for manic episodes. Which laboratory results would be most concerning to the nurse?

sodium 150 mEq/L (150 mmol/L), hemoglobin 19.2 g/dL (192 g/L), blood urea nitrogen (BUN) 38 mg/dL (13.57 mmol/L)

Which approach should be used with a client with paranoid personality disorder who misinterprets many things the health care team says?

speak in simple messages without details

A nurse notes that a client frequently coughs while eating. The licensed practical nurse (LPN) reports this finding to the registered nurse and discusses possible options to address this problem. Based on the discussion, which health team member would the LPN expect to become involved?

speech therapist

A client is treated in the emergency department with reports of dyspnea, cough, and sharp pain that increases with exertion. The nurse auscultates diminished breath sounds, and the health care provider prescribes a chest x-ray. What does the nurse suspect this will indicate?

spontaneous pneumothorax

A nurse is reinforcing the teaching plan for a postpartum client diagnosed with mastitis. The nurse determines that the client has understood the information when she states which organism as most likely responsible?

staphylococcus aureus

The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called?

statute of limitation

The nurse is obtaining a dietary history from a newly admitted client. Which food eaten by the client does the nurse recognize is a common allergen?

strawberries

A client with antisocial personality disorder tells a nurse, "Life has been full of problems since childhood." Which condition would the nurse explore in the assessment?

substance abuse

A 13-year-old with structural scoliosis has Cotrel-Dubousset rods inserted. Which position would be best during the post-operative period?

supine in bed

Which symptom is the most common manifestation of severe combined immunodeficiency disease (SCID)?

susceptibility to infection

The nurse is reinforcing education for the parents of a child with growth hormone deficiency. Which sport does the nurse suggest as the most beneficial for the child? Select all that apply.

swimming gymnastics

An infant with hypothyroidism is receiving oral thyroid hormone. Which finding should alert a nurse to a potential overdose?

tachycardia, irritability, and diaphoresis

A nurse is caring for a 1-day postpartum client. The progress note above informs the nurse that the client is in which phase of the postpartum period?

taking in

A client tells the nurse "my cowaorkers are sabotaging my computer." When the nurse asks questions, the client becomes argumentative. Which intervention would be most appropriate for the nurse to implement?

talk with the client about the realistic situations

A client tells the nurse "my coworkers are sabotaging my computer." When the nurse asks questions, the client becomes argumentative. Which intervention would be most appropriate for the nurse to implement?

talk with the client about the realistic situations

The nurse is caring for a neonate that was born to a mother with gestational diabetes. What site will be used to puncture the neonate's foot in order to monitor the neonate's glucose level?

the lateral aspect of the heel

A client with bipolar disorder has abruptly stopped taking prescribed medication. Which behavior would indicate the client is experiencing a manic episode?

thoughtless spending

A nurse gathers data on a client who has developed a paralytic ileus. Which type of bowel sounds should the nurse anticipate hearing?

three to four peristaltic sounds per minute

Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder?

to prevent or relieve symptoms of anxiety

A multiparous client has given birth vaginally to a healthy neonate. It is now her first postpartum day. Which factor would the nurse identify as putting this client at risk for developing hemorrhage?

uterine atony

The nurse is reviewing the medical record of a client who is 6 weeks postpartum and came for a follow up appointment with her health care provider. The client's uterus is enlarged and soft, and she is experiencing vaginal bleeding. Based on the findings, which condition would the nurse most likely suspect?

uterine subinvolution

A client with Bipolar I disorder is experiencing mania. How will the nurse best communicate with this client?

verbalize self-confidence in own abilities

A school nurse is obtaining data from a student at an elementary school. Which finding would lead the nurse to suspect impetigo?

vesicular lesions that ooze, forming crusts on the face and extremities

A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with:

water.

During data collection, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:

waxy flexibility.

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should:

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.

A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain?

willingness to learn

The nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to:

withhold the suppository and notify the client's physician.

A physician is administering a medication by intraosseous infusion to a child. Intraosseous drug administration is typically used for a child who is:

younger than age 3 in an emergency situation when I.V. access isn't available.

A licensed practical nurse (LPN) is assisting with the admission of a client to the medical-surgical unit. While gathering data about the client, the LPN asks the client if an advance directive has been prepared. The client responds, "I don't know what you mean." Which response by the nurse would be most appropriate?

"An advance directive is a document that states your wishes about health care."

Which statement by the nurse accurately explains the need for a client with hypertension to obtain an annual eye exam?

"By examining the retina in your eyes, an ophthalmologist can detect changes in the arteries in your eyes."

A nurse is caring for a neonate who has hypospadias. His parents are asking about having the baby circumcised before discharge. When reinforcing education with the parents about their child's condition, what should the nurse tell them?

"Circumcision is delayed as the foreskin is needed for surgical correction.

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client?

"Cover the area when in direct sunlight."

A client is receiving warfarin for the treatment of atrial fibrillation. What education should the nurse reinforce regarding this medication? Select all that apply.

"Do not increase your intake of green leafy vegetables." "Use a soft toothbrush for cleaning your teeth." "You will need to have your blood drawn for laboratory examination frequently."

A client arrives at the clinic for a scheduled amniocentesis. Which question should the nurse ask?

"Have you emptied your bladder?"

An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates an understanding of the nurse's teaching?

"I clean my teeth gently several times a day."

A client diagnosed with systemic lupus erythematous (SLE) is experiecing an exacerbation. Which statement made by the client indicates further education should be reinforced?

"I don't have to worry if I get strep throat."

A client is admitted to the behavioral health unit for treatment of pedophilia and tells the nurse that the client doesn't want to talk about sexual behaviors. Which response from the nurse is most appropriate?

"I know this must be difficult for you."

A client is admitted for pneumonia secondary to human immunodeficiency virus (HIV). The nurse asks unlicensed assistive personnel (UAP) to give the client a bed bath. The UAP is hesitant to bathe the client for fear that he or she will contract the virus. Which statements would be most appropriate for the nurse to include in the response? Select all that apply.

"I know you're frightened, but by taking proper precautions, there's little to no risk of acquiring HIV." "The use of personal protective equipment (PPE) may prevent the unintentional transmission of diseases in situations where you may come in contact with blood, body fluids, or secretions."

The nurse is reinforcing teaching with a client how to take nitroglycerin to treat angina pectoris. Which statements indicate that the client understands the potential side effects of nitroglycerine? Select all that apply.

"I may experience a pounding headache." "I may feel dizzy." "I may feel flushed."

A client with type 1 diabetes is at 22 weeks' gestation after the first pregnancy ended in spontaneous abortion at 18 weeks' gestation. The nurse is reinforcing instructions with the client about exercise during her pregnancy. Which statement indicates that the client has an appropriate understanding of her exercise needs?

"I need to walk with a friend or family member."

The nurse is reinforcing education for a client diagnosed with gastroesophageal reflux disease (GERD) regarding preventative measures to reduce symptoms. What statement made by the client requires further reinforcement?

"I should lie flat after I eat my meals."

A client needs to have a fecal occult blood test performed on three consecutive bowel movements. To prepare the client for this test, the nurse provides information about the required dietary restrictions. The nurse knows the teaching has been successful when the client makes which statement?

"I should not eat any poultry, red meat, and turnips for 4 days before I begin this test."

Which statement by a client with sickle cell disease indicates further education is needed to reinforce the therapeutic regimen?

"I should take one baby aspirin daily to help prevent sickle cell crisis."

A nurse has instructed a client about taking ferrous sulfate liquid preparation. Which statement by the client indicates the need for additional education?

"I should take the iron with an antacid to prevent gastric distress."

Propranolol has been prescribed for a teen who has been diagnosed with hypertension. When discussing the medication with the teen, which statement indicates the need for further instruction?

"I should take this medication daily on an empty stomach."

The nurse is reinforcing discharge instructions to a client with chronic cholecystitis. Which response by the client indicates the education has been effective?

"I will take my anticholinergic medications as prescribed."

The nurse is reinforcing teaching instructions to a client with trigeminal neuralgia on how to minimize pain episodes. Which comments by the client would indicate correct understanding of instructions? Select all that apply.

"I'll chew food on the unaffected side." "I'll drink fluids at room temperature." "I'll perform mouth care after meals.

A 78-year-old client with type 2 diabetes needs a kidney transplant. The client's daughter volunteers to donate a kidney, but the client voices concerns about her daughter's health to the nurse. Which response by the nurse is appropriate?

"I'll notify your physician of your concerns and see if he can discuss the procedures with you."

A client with dependent personality disorder is working to increase self-esteem. Which statement by the client shows that the education was successful?

"I'm not just going to look at the negative things about myself."

The nurse is meeting with a 17 year-old client who has recently tested positive for human immunodeficiency virus (HIV). The client states, "What information will be disclosed to others." What information should be provided by the nurse?

"In some jurisdictions laws may require you share this information with future sexual partners."

A 2-year-old child is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The parent asks about treatment of the disease. What would be an appropriate response from the nurse?

"Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum."

A nurse is reinforcing education to the parents of an 18-month-old infant diagnosed with bilateral otitis media about the prescribed medication amoxicillin and clavulanate potassium. Which statement by the parents indicates the education has been effective?

"It can cause diarrhea."

The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching?

"It is all right to French kiss my partner."

A newly hired graduate nurse is caring for a client prescribed a carminative enema. When discussing the plan of care with the nurse mentor, which appropriate information would the graduate state that provides an understanding of a carminative enema?

"It is given into the rectum to help expel flatus to relieve distention."

A nurse is caring for a client with otosclerosis who is scheduled for stapedectomy. The client asks the nurse when the client's hearing will improve. Which response by the nurse is most appropriate?

"It might take as long as 6 weeks for your hearing to improve."

The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. Which statement by the nurse about aspirin would be most accurate?

"It's contraindicated because it promotes bleeding tendencies."

The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?

"It's inappropriate to refuse this assignment; all clients should be treated equally."

A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best?

"It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)."

A client diagnosed with major depression has started taking amitriptyline hydrochloride. The nurse is reviewing the instructions about this drug and potential adverse effects. The nurse determines that the client has a good understanding of the drug therapy based on which client statement?

"It's not unusual for this drug to make my mouth feel a bit dry."

The health care provider has ordered a check of glycosylated hemoglobin (HbA1c) levels for a client with diabetes. Which statement by the client regarding this test indicates that education has been effective?

"It's used to monitor the control of my disease."

A nurse is reinforcing education for the parents of a child who has been diagnosed with spina bifida. Which statement by the parents would indicate an understanding of spina bifida?

"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately."

Criteria for rheumatic fever are being discussed with parents. The nurse realizes that the parents understand chorea when they make which statement?

"My child might have difficulty in school."

A client develops a pulmonary embolism after total knee replacement surgery and must be converted from heparin to warfarin anticoagulant therapy. What should the nurse inform the client is the reason for the change in the treatment plan?

"Prothrombin time (PT) and international normalized ratio (INR) will be checked for dose adjustment."

A geriatric client is admitted to acute care following a fall. The client is only able to provide a name during the admission phase. The caretaker reports that the client is usually alert and oriented and expresses concern about the client's confusion. Which response is most appropriate?

"Stress related to an unfamiliar situation can cause short-term confusion in older adult clients."

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. When asked by the newly graduated nurse, what type of hearing loss it is, how would the nurse preceptor respond?

"This type of loss is a conductive hearing loss."

On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response?

"To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here."

A nurse is providing care for a pregnant client who asks how she can best deal with her fatigue. Which instruction would the nurse most likely reinforce with the client?

"Try to get more rest by going to bed earlier."

The health care provider orders digoxin 0.1 mg orally every morning for a 6-month-old infant with heart failure. Digoxin is available in a 400 mcg/mL concentration. How many milliliters of digoxin should the nurse give? Record your answer using two decimal places.

0.25

At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse how much calcium she should consume. The nurse tells her that the recommended daily calcium intake for premenopausal women is:

1,000 to 1,200 mg.

The nurse is caring for a child with a urinary tract infection. The health care provider has ordered cephalexin 125 mg by mouth every 8 hours. Cephalexin is available 250 mg per 5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.

2.5

A 22 lb (10 kg) child is diagnosed with Kawasaki disease and started on gamma globulin therapy. The health care provider orders an IV infusion of gamma globulin, 2 g/kg, to run over 12 hours. How many grams should the nurse give the client? Record your answer using a whole number.

20

The physician prescribes an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, the client should receive how many milliliters of I.V. fluid per hour?

120 ml/hour

The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra?

2" (5 cm)

The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which indicates the therapeutic range for this client?

2.0 to 3.0

A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection?

3 to 7 days

The nurse receives a health care provider's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31

A nurse is caring for the following clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes?

A client who reports genital pruritus and paresthesia

A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?

A client with bilateral blindness

The nurse assesses a neonate with esophageal atresia for signs of dehydration. Which finding should the nurse expect to see?

A sunken anterior fontanel

A nurse is teaching a women's group about ovarian cancer. Which client is at the highest risk for this disease?

45-year-old client who has never been pregnant

A 10-year-old client with asthma is prescribed 2 mg of albuterol syrup four times per day. The syrup comes in a dosage strength of 2 mg/5 ml. How many milliliters of syrup should the nurse administer? Record your answer using a whole number.

5

A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?

42 drops/minute

The health care provider prescribes 60 mEq of potassium chloride liquid as a one-time dose. The pharmacy supplies a liquid containing 20 mEq/15 ml. How many milliliters will the nurse administer? Record your answer using a whole number.

45

A 3-year-old is to receive 500 mL of dextrose 5% in normal saline solution over 8 hours. At what rate (in milliliters per hour) should a nurse set the infusion pump? Round your answer to a whole number.

63

The nursing instructor asks a nursing student approximately how much time is required for the blastocyst to reach the uterus for implantation. What timeframe does the student provide to the instructor?

7 days

A client with a diagnosis of tuberculosis (TB) is informed he will have to take medication for the treatment of the disease. How long does the nurse inform the client he will have to be compliant with treatment?

9 to 12 months

A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client.

A healthy, pregnant woman is diagnosed with varicose veins. What should the nurse reinforce with this client to help her avoid further development of the disease? Select all that apply.

Elevate the legs. Change positions. Monitor weight.

A 19-year-old client with cystic fibrosis is admitted to the hospital in acute respiratory distress. The client's mother tells a nurse that the client has been unable to get out of bed for the past month. While assessing the client, the nurse notes a stage II pressure ulcer on the client's sacrum. Which action is most important to include in the client's plan of care?

Accurately document the appearance, size, location, and odor of the wound, and consult a wound care nurse.

The physician diagnoses leukemia in a child, age 4, who reports being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the pathophysiology behind leukemia?

Activity intolerance related to anemia

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should include which measure?

Administering large doses of I.V. antibiotics as prescribed

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition?

Affect

A client is admitted for right leg vein ligation and stripping for varicose veins. Which nursing intervention postoperatively should the nurse include?

Ask the client to elevate the legs when sitting.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority?

Ask the client when she last changed her perineal pad.

The nurse is caring for a patient with diabetes who is lethargic and has developed rapid, deep respirations. Which action should the nurse take?

Assess glucose level.

Which is the highest priority performed by the nurse prior to completing this nursing action?

Assess stomach residual.

The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity

A nurse is caring for a client with active tuberculosis who is homeless. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which nursing intervention would best promote adherence with the treatment plan after discharge?

Assist with referring the client to a social worker for discharge.

A nurse tells a client in labor, "If I were you, I'd ask the doctor for something for pain; you shouldn't have to suffer during labor." Which ethical principle is the nurse promoting?

Autonomy

A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing:

a hemolytic allergic reaction caused by an antigen reaction.

The nurse evaluates a client who is 36-hours postoperative. Which sign or symptom indicates to the nurse that the client is experiencing a complication?

a warm, erythematous tender incision

The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

By supplying a magic slate or similar device

The nurse is caring for a terminally ill school-age child. Which resource might be most helpful in caring for this child?

Child life specialist

A client with a recent fracture is suspected of having compartment syndrome. Which findings does the nurse recognize correlate with this diagnosis?

inability to perform active movement; pain with passive movement

The nurse should include which in-home management instruction for a child who's receiving desmopressin acetate for symptomatic control of diabetes insipidus?

Call the health care provider for an alternate route of desmopressin acetate when the child has an upper respiratory infection (URI) or allergic rhinitis.

The nurse is initiating an intravenous (IV) access for a client who needs an infusion of normal saline solution. Which nursing action should the nurse perform before the venipuncture?

Check for latex allergy before applying the tourniquet.

A client who's aphasic and has left-sided paralysis after sustaining a stroke is scheduled for debridement of a left leg ulcer. Whenever passive range-of-motion (ROM) exercises are performed on the left leg, the client grimaces and moans. Which action should the nurse take before the physician performs the debridement?

Check the client's medication administration record to see when he last received pain medication and administer a dose, if appropriate, before debridement.

A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.

Check vital signs. Notify the RN. Check the fundal height.

The nurse is checking the fetal heart rate (FHR) of a client admitted to the labor and delivery area and notes an FHR of 144 beats per minute associated with a 10 beats per minute short-term variability. Which of the following action should the nurse take?

Continue to monitor the client

After a 33-year-old male client displays violent behavior, he is placed in restraints. Which intervention by the nurse takes priority for this client?

Continuously monitoring the client

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve will the nurse assess to determine if it is functioning so the client can chew?

Cranial nerve V

The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse's best intervention?

include the client in the decision-making process

A client taking a new prescription for propranolol calls the clinic to report a weight gain of 3 lb (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?

Due to fluid accumulation, have the client assessed for worsening heart failure by the health care provider.

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the client's medication drawer. What priority action should the nurse implement?

Discard the syringe to avoid a medication error.

A 62-year-old male client with schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?

Document the details of the conversation and notify the nursing supervisor.

A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God because of the diagnosis. Which nursing intervention is appropriate for this client?

Encourage the client to speak with a clergy member.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is appropriate?

Encouraging increased fluid intake

The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families?

Escort the family who received the discouraging news to a private area.

Yesterday, a client with schizophrenia began treatment with haloperidol. Today, the nurse notices that the client is holding his head to one side and is reporting neck and jaw spasms. What should the nurse do?

Evaluate the client for adverse reactions to haloperidol.

A nurse is caring for a client who is placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Evaluate the extremity for paleness and edema.

A neonate weighs 7 lb, 3 oz at birth. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and observes the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should provide what suggestions to the mother? Select all that apply.

Make sure that the newborn's temperature is maintained within normal range. Observe the stool for amount and characteristic. Encourage early and frequent feedings.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation?

Measles

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate?

Notify the physician of the client's lack of progress and request a diabetes education department consult.

The nurse is caring for multiple clients that have been determined to be at risk for falls. Which intervention(s) should the nurse institute to prevent falls? Select all that apply.

Orient client to the nurse call system and encourage its use. Ensure the nurse call system is within reach. Keep hospital bed in low position.

An adolescent female client has begun menstruation. The nurse teaches the client about dietary intake of which nutrient?

Iron

A 4-year-old client has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first?

Irrigate the NG tube to ensure patency.

A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take?

Look at the chart for his last potassium level and contact the physician.

A client is scheduled to have a cholecystectomy. In the preoperative teaching, the nurse explains that incentive spirometry will be used after surgery. Which information will the nurse include when conducting the postoperative teaching? Select all that apply.

increase alveolar inflation promote lung expansion promote deep breathing

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the client's right arm, and the left arm and hand should be elevated as much as possible to prevent which condition?

Lymphedema

The nurse is to administer the morning dose of NPH insulin to a client with type 1 diabetes. The client is alert and oriented; before administering the medication, the nurse obtains a glucose reading of 52. What should the nurse do at this time?

Give the client breakfast and then recheck the glucose level.

A client, age 23, is diagnosed with type 1 diabetes. The physician prescribes 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles the appropriate equipment, washes her hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

Inject 35 units of air into the NPH vial; inject 15 units of air into the regular insulin vial and withdraw 15 units of regular insulin; and withdraw 35 units of NPH.

When children are more physically active, which change in the management of the child with diabetes should the nurse expect?

increased food intake

Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg?

Instruct the client to breathe into a paper bag.

A client with advanced cancer of the mouth has a swollen, necrotic, and weeping tongue. Which nursing intervention should be a priority in planning care?

Maintain a patent airway.

A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. Which intervention is most important for the nurse to perform?

Maintain a patent airway.

A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client?

Maintain a patent airway.

Which finding will the nurse most likely observe when performing a health screening of an older adult female client who has loss of bone density?

increased thoracic curvature of the spine

A client with a diagnosis of bulimia nervosa is working on relationship issues. Which nursing intervention is most important?

Facilitate the client's ability to identify feelings about relationships.

A client is admitted with chronic obstructive pulmonary disease (COPD). Which nursing actions should the nurse perform for this client? Select all that apply.

Maintain adequate airway for client. Educate client on smoking and other triggers. Teach pursed lips breathing technique to client . Assess pulse oximetry .

A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which goal of care?

Maintaining effective respirations

A preschool-age child underwent a tonsillectomy 4 hours ago. Which data collection finding would make the nurse suspect postoperative hemorrhage?

Frequent swallowing

The nursing instructor is demonstrating a head-to-toe assessment. Which plane would the instructor use to divide the body longitudinally into anterior and posterior regions?

Frontal plane

The nurse is teaching a client with osteomalacia how to take prescribed vitamin D supplements. The nurse stresses the importance of taking only the prescribed amount because high doses of vitamin D can be toxic. Early signs and symptoms of vitamin D toxicity include:

GI upset and metallic taste.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. Based on the data, which intervention should the nurse do first?

Gather information on the client's airway, breathing, and circulation.

When collecting data on a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). The nurse recognizes which condition makes this client more susceptible to such infections?

Glycosuria

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

Granulocytopenia

Which of the following techniques is most effective in preventing nosocomial infection transmission when caring for a preschooler?

Hand washing

What should a male client older than age 50 do to help ensure early identification of prostate cancer?

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

The nurse is gathering data from an older adult client with a fracture. Identify the location of the most common fracture in older adults to cause death within 1 year of sustaining the fracture.

Hip

A nurse is preparing a lecture for a prenatal class. Which hormone would the nurse include in the presentation as being responsible for maintaining pregnancy during the first 3 months?

Human chorionic gonadotropin (hCG)

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which of the following problems?

Hypercapnia, hypoventilation, and hypoxemia

When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone. When caring for this client, the nurse should monitor for which adverse drug reactions?

Increased weight, hypertension, and insomnia

Which documentation is most important when preparing a preschool-age child for surgery?

Informed consent

When receiving a client assignment, which assignment should the licensed practical nurse (LPN) recognize as being outside of the LPN scope of practice? Select all that apply.

initiating a blood transfusion completing an initial admission assessment

A client who has a pulmonary embolism has the potential to develop chest pain. What would be the nurse's best explanation for this when reinforcing education for the client?

It is pleuritic pain due to inflammation.

Which characteristic of the fascia can cause it to develop compartment syndrome?

It is unable to expand.

A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on the foot. Which statement regarding the rationale for using electrocautery to treat the injury is most accurate?

It's used to relieve pain and reduce the risk of infection.

When collecting data on a 5-year-old child with hemophilia, the nurse identifies which of the following as an early sign of hemarthrosis?

Joint stiffness

The nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children?

Kidneys

The mother of a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to which of the following?

Latex

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?

Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

A nurse is reviewing a client's medication blood level values for a commonly administered psychiatric medication. Which medication, prescribed in individualized dosages according to the blood levels of the drug, would the nurse expect to find in this client's medication orders?

Lithium carbonate

The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. Which nursing intervention takes priority?

Locating a staff member who can interpret the discharge instructions.

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan?

Metallic taste

A 76-year-old client with no debilitating conditions belongs to which geriatric population?

Middle-old

The nurse is assessing a client with heart failure. Which heart valve sound will the nurse hear best at the fifth left intercostal space at the midclavicular line?

Mitral

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?

Moist sterile saline gauze

The nurse is caring for a client who vomits 1 hour after taking a morning glyburide. What is the priority nursing action?

Monitor blood glucose closely and look for signs of hypoglycemia.

The nurse is assisting with the care of an infant following surgical repair of esophageal atresia and tracheoesophageal fistula. Which nursing intervention takes the highest priority during the first 24 hours following the surgical repair?

Monitor for excessive secretions.

The nurse is caring for an adolescent client receiving a selective serotonin reuptake inhibitor (SSRI) as part of the treatment plan for anorexia nervosa. Which action is a priority intervention related to the SSRI therapy?

Monitor for suicidal thoughts.

What is an appropriate nursing intervention for a client with a soft wrist restraint?

Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm

Which nursing intervention would be the priority in the immediate postoperative care of a client who has undergone gastric resection?

Monitoring for symptoms of hemorrhage

When caring for a client who has had a cesarean section, which of the following actions is appropriate?

Monitoring pain status and providing necessary relief

A client with Crohn's disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?

Move him to the next available window-side bed.

Which aspect of drug therapy is most important when planning nursing care for an elderly client?

Noncompliance

A nurse is caring for a client who sustained a gunshot wound to the leg during a jewelry store robbery. The client is in police custody and receiving treatment in the emergency department. A member of the media asks the nurse about the client's condition. How should the nurse respond?

Notify the nursing supervisor so she can obtain a formal statement from the physician about the client's condition for the media.

The LVN/LPN suspects narcotic diversion when a particular nurse volunteers to administer medication to clients when they call for pain medication and the clients continue to report pain. What should the nurse do?

Notify the nursing supervisor.

A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene?

Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output

Which intervention should be included in the plan of care for a 6-month-old infant with mild dehydration related to diarrhea and vomiting?

Oral electrolyte replacement solutions, breast milk, or lactose-free formula

The nurse prepares to administer a client's morning medication. Which action should the nurse take first?

Perform hand hygiene.

A client who is receiving cyclosporine must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drugs falls into this category?

Phenytoin

A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?

Pick up the implant with long-handled forceps and place it in a lead-lined container.

The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?

Place a hand under the child's head for support.

A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan?

Place the baby in an upright position when giving a bottle.

Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position?

Place the child on the hip.

A child has just returned to the pediatric unit following ventriculoperitoneal shunt placement for hydrocephalus. Which intervention would the nurse perform first?

Place the child on the side opposite the shunt.

A 2-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which nursing action would be appropriate for the nurse to perform first?

Place the toddler in respiratory isolation.

The nurse is caring for an unconscious client who suffered a stroke 4 days ago. When providing oral hygiene for this client, the nurse must take which essential action?

Placing the client in a side-lying position

The nurse is caring for a 10-year-old client with cardiac failure who is on bed rest. The client is crying because of boredom. Based on the client's developmental growth, which appropriate action would the nurse implement to eliminate this client's boredom?

Play a game of checkers with the client.

Two staff nurses on the urology unit are responsible for the unit schedule. The holidays are nearing, and many staff members would like to take vacation days. Which method might fairly solve the holiday staffing problem?

Poll the staff to find out their preferences.

A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How can the nurse promote oxygenation in this client? Select all that apply.

Position client in Fowler's position. Decrease anxiety in the client. Set the line marked "2" so it cuts the ball in half.

When caring for a client who's having her second baby, the nurse suspects cephalopelvic disproportion. Which action should the nurse take?

Prepare for a cesarean birth.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that's specific to heparin. Which agent fits this description?

Protamine sulfate

Which nursing intervention is the best way to help reduce the occurrence of poisoning in children?

Provide education to those who care for children.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours?

Provide frequent early feedings with formula.

The nurse cares for a client who is post-op bowel resection and has a nasogastric (NG) tube to low intermittent suction. Which care intervention should the nurse administer?

Provide meticulous mouth care as needed.

A 32-year-old homeless client is referred to an outpatient treatment program for delusional behavior. A nurse notes during the history-taking process that the client eats only one meal a day, which is high in fat and contains no vegetables. The client also states that she rarely eats fruit. Which approach can the nurse use to help the client eat more nutritious meals?

Provide the client with a nutritional lunch and arrange for the nutritionist and psychiatrist to see the client after lunch.

A girl, age 15, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is most effective?

Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model

Four clients on an orthopedic unit are scheduled to attend physical therapy at the same time. Facility policy dictates that each client be escorted to therapy in a wheelchair or on a stretcher. When it's time for therapy, only three wheelchairs are available. One of the four clients is learning crutch-walking and is scheduled for discharge in the morning. What should the nurse do to ensure the clients' safety and timely arrival to physical therapy?

Request that a physical therapist accompany the client to therapy while he uses the crutches.

An incarcerated client is admitted to the hospital after sustaining multiple contusions and a fractured femur in an assault. After surgical repair of the femur, the client develops paralytic ileus. A nasogastric (NG) tube and cleansing enemas are prescribed. The client has a prison guard assigned to his bedside. How should a nurse proceed to implement a physician's orders?

Request that the guard remain outside the client's door during the prescribed procedures.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Restricting fluids

The nurse is developing a teaching plan for a client receiving clozapine. The nurse should stress the importance of which aspect of follow-up care?

Routine complete blood count (CBC) with differential

When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?

She should report the finding as hypospadias.

A 40-year-old executive who was unexpectedly laid off from work 2 days ago reports fatigue and an inability to cope. He admits drinking excessively over the last 48 hours. This behavior is an example of which condition?

Situational crisis

A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?

Standard precautions

A parent brings a child to the health care provider's office because the child reports pain, redness, and tenderness of the left index finger. The child is diagnosed with paronychia. Which organism is the most likely cause of this superficial abscess of the cuticle?

Staphylococcus species

A client receiving total parental nutrition is prescribed a 24-hour urine test. The nurse delegates the collection of the specimen to the unlicensed assistive personnel (UAP). The nurse is aware that the UAP is collecting the specimen correctly when he or she initiates the collection in which instance?

Start after a client's known voiding that empties the bladder

A nurse is gathering data on a client receiving an enteral feeding who suddenly states, "I feel very faint and sweaty." What is the nurse's immediate action?

Stop the feeding.

A nurse is caring for a 10-year-old child hospitalized for treatment of acute osteomyelitis. The child's left leg is immobilized in a splint. What is the nurse's most appropriate action?

Support and handle the leg gently during turning and repositioning.

A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse drug effect?

Tachycardia

The nurse is obtaining vital signs for a client with a seizure disorder. Which method would the nurse use to obtain the most accurate measure?

Take an axillary temperature instead of an oral temperature.

After collecting a urine specimen, which action by the nurse is most appropriate?

Take the specimen to the laboratory immediately.

The nurse suspects that a client is not swallowing the administered dose of an anxiolytic medication and is concerned that the client may be disposing of it in the trash. Which action should the nurse take first?

Talk with the client about the concerns.

The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should expect the health care practitioner to prescribe which medication?

Tamoxifen

A client with anorexia nervosa describes herself as "a whale." However, the nurse's data collection reveals that the client is 5' 8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the plan of care?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy

Which assessment finding indicates that the infant latch during breast-feeding needs further intervention?

The baby's lips smack.

One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart?

The child rates pain at 4 out of 5. Pain medication administered as prescribed.

A school-age child is being discharged with a diagnosis of rheumatic fever. Which of the following should be included in the teaching plan for the family?

The child should stay on penicillin and return for a follow-up appointment.

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. What does this evaluation determine for the client?

The client can see at 20 feet what the person with normal vision sees at 40 feet.

Propranolol 80 mg PO BID has been ordered by the health care provider. The nurse reinforces teaching of this medication. Which indicates teaching has been successful?

The client checks pulse for bradycardia.

A nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which of the following criteria excludes the client from hospice care?

The client entered a clinical trial through the National Cancer Institute.

A client comes to the clinic and informs the nurse they may have been exposed to a family member with tuberculosis. The nurse administers the tuberculin skin test, and 2 days later the test is positive. What does the nurse determine the results mean?

The client had presence of infection at some point.

A client with Alzheimer's disease is being treated for injuries from a recent fall and malnutrition. The nurse determines a need to place the client closer to the nurse's station based on which finding?

The client has a tendency to wander.

A client's prenatal history shows the client to be a 23-year-old gravida 4, para 2. The nurse has correctly interpreted this information when making which statement?

The client has been pregnant four times and delivered two live-born children.

Upon admission to a long-term care facility, a client is administered a Mantoux test. The nurse reads the test in 48 hours and observes a 5-mm induration. What does this indicate to the nurse?

The client has produced an immune response to the tuberculosis bacteria.

When reviewing a client's chart, the nurse sees the progress note. Which statement about the client's condition is most accurate?

The client may not be motivated to change their behavior or their lifestyle.

A client who is being treated in the emergency department with a diagnosis of status asthmaticus is prescribed beta-adrenergic agents and intravenous (I.V.) corticosteroids. What does the nurse identify as an indication that the treatment is not working?

The client needs to be intubated.

After having a transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void.

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts?

The client should continue using contraception during periods of amenorrhea.

The nurse is teaching the client how to use a cane. Which statement is inaccurate?

The client should hold the cane on the involved side.

A nurse is caring for a client diagnosed with borderline personality disorder. Which action by a client indicates adequate learning about personal behavior?

The client talks about intense anger.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor him closely for:

atelectasis.

A nurse is caring for a client with fluid volume excess. Which nursing care outcome is desired for this client?

The client will have clear breath sounds in all lung fields.

A nurse is preparing to care for a client with Ménière disease. Which priority outcome should the nurse implement?

The client will not fall when attempting to stand during the 07:00 to 15:00 shift.

Parents of an adolescent are concerned that their child has been irritable, hasn't been sleeping for 6 months, and is not engaging in social activities. Which outcome developed by the health care team would be appropriate for this client?

The client will obtain appropriate mental health services.

A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals should the nurse determine as priority?

The client will work with the nurse to remain safe.

A 9-month-old infant is scheduled for an inguinal hernia repair. The divorced parents share joint custody of the infant. What determines who can give informed consent for the procedure?

The divorce decree should specify which parent has the right to sign the informed consent form.

A nurse is caring for a pregnant client who is scheduled to undergo an amniotomy to induce labor. After the procedure, which client goal should take the highest priority?

The fetus will maintain adequate tissue perfusion.

The nurse is caring for a 6-week-old infant with laboratory results indicating fluid and electrolyte imbalance. Which nursing consideration is most important?

The infant has immature kidney function.

The nurse realizes she's 1 hour late in administering a dose of medication for her 4-year-old client. She gives the medication immediately and assesses the client. The client isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error.

A 10-year-old child is in the hospital for the first time. The nurse has provided support and teaching to help the family and child adjust and to reduce their anxiety related to the child's hospitalization. Which of the following would the nurse view as unexpected? You Selected: The child discusses procedures and activities without evidence of anxiety.

The parents choose to leave to let the child build a relationship with the staff.

The nurse inadvertently gives a client a double dose of a prescribed medication. After discovering the error, whom should the nurse notify?

The prescriber

An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim?

The tongue

The nurse finds the family member of a client in the nutrition room standing in a puddle of water holding the microwave door, shaking. What should the nurse do first?

Unplug the microwave.

The nurse educator is preparing an in-service about urinary incontinence in the elderly. Which information should the nurse share with her colleagues describing urinary incontinence in the elderly?

Urinary incontinence is not a disease.

Which information should the nurse include when reinforcing instructions for a client about using vaginal medications?

Use a water-soluble lubricant when inserting a suppository.

A nurse is caring for a 15-year-old pregnant adolescent who is taking an iron supplement. After reviewing instructions for taking the iron supplement, the nurse determines that the teaching was successful when the client tells the nurse that she will take the supplement with which fluid to help increase the absorption of iron?

a glass of orange juice

An 11-year old girl with reports of dysuria is suspected of having a urinary tract infection. Which findings on the laboratory report are consistent with a urinary tract infection?

WBCs: 20 per high-power field

An 11-year-old girl comes into the health care provider's office reporting dysuria. Which findings on the laboratory report are consistent with a urinary tract infection?

WBCs: 20 per high-power field

A client with diabetes who had a stroke has right-sided paralysis and incontinence and is in the rehabilitation center. Which action should be the nurse's priority in caring for the client?

Wash the client's skin with soap and water, gently patting it dry.

A family expresses concern that a relative who stopped using amphetamines 3 months ago is acting paranoid. Which explanation by the nurse is best?

When a person uses amphetamines, paranoid tendencies may continue for months.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure?

White blood cell (WBC) count of 20,000/mm3

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions?

With the heel of one hand

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

With the leg on the affected side abducted

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client?

Within 2 weeks

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:

a barium enema.

A woman in her eighth month of pregnancy is having dinner with her husband at their favorite restaurant. The woman suddenly begins choking on a piece of chicken. The client's husband yells out, "Please somebody help us!" A licensed practical nurse is sitting at the next table and offers to help. Which action would the nurse most likely perform?

a chest thrust

The charge nurse is making assignments for nurses working on a medical surgical unit. Which clients could be assigned to the licensed practical nurse (LPN)? Select all that apply.

a client in need of tracheostomy dressing a client in need of Foley catheterization a client on tube feeding who needs the nasogastric tube checked for patency a diabetic client who needs reinforcement of teaching on insulin administration

A client, who is newly prescribed metoprolol, has a headache and asks the nurse what medication to take. The nurse should reinforce the health care provider's instructions to take which of the following medications?

acetaminophen

An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder?

acute pulmonary edema

Which intervention does the nurse determine has the most impact in delaying the development of acquired immunodeficiency syndrome (AIDS) once a client has been infected with human immunodeficiency virus (HIV)?

adherence with the complete therapeutic regimen

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action is to:

administer an as-needed dose of benztropine I.M. as ordered.

Which instructions should the nurse include when reinforcing education to the parents about caring for a child with chickenpox?

administer antipruritics as ordered

Which nursing intervention is most effective in maximizing tissue perfusion for a child in vaso-occlusive crisis?

administer oxygen as prescribed

A nurse is caring for a client with left-sided heart failure. Which intervention takes priority in this client's care?

administering diuretics

A nurse is caring for a client with osteoarthritis. What collaborative treatment strategy should the nurse anticipate participating in for this client?

administering nonsteroidal anti-inflammatory drugs for pain control

An LVN/LPN working on a busy unit decides to delegate some tasks to the unlicensed assistive personnel (UAP). Which client tasks can be delegated to the UAP? Select all that apply.

ambulation of a client intake and output measurement positioning a client

A client has not voided for 10 hours following an inguinal hernia repair. Which factor may place a surgical client at risk for urine retention?

anticholinergic medication before surgery

The nurse is caring for a client receiving the fentanyl transdermal system for pain management. When applying a new system, the nurse should:

apply the system immediately after removal from a package.

A client with Alzheimer's disease begins supplemental feedings through a gastrostomy tube to provide adequate calorie intake. What should the nurse be most concerned about with this client?

aspiration

A nurse is caring for a client who's receiving enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as for residual volume. The purpose of the nurse's actions is to prevent which life-threatening complication?

aspiration

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

changes from previous self-examinations.

A nurse is caring for a client who is receiving enteral feedings through a feeding tube. Which action takes priority in this client's care?

checking placement of the tube

The nurse is reinforcing education about treatments for the parents of a child diagnosed with pneumonia. What does the nurse identify as the best action to help in promoting a clear airway?

chest physiotherapy

While gathering data about a child's skin integrity, the nurse observes a papular pruritic rash with some vesicles. The rash is profuse on the trunk and sparse on the distal limbs. What does the nurse correlate this finding with?

chickenpox

A client on the behavioral health unit spends several hours per day organizing and reorganizing the closet, repeatedly checking to see if clothing is arranged in the proper order. How does the nurse interpret this behavior?

compulsion

The nurse cares for a client who is recovering from general anesthesia. Which finding indicates to the nurse that the client is experiencing a complication?

decreased bibasilar breath sounds

The client is being evaluated for hypothyroidism. The nurse should stay alert for:

decreased body temperature and cold intolerance.

When collecting data on an infant diagnosed with pyloric stenosis, which finding should the nurse anticipate?

decreased bowel sounds

The nurse is caring for a client with a cognitive disorder. Which characteristic does the nurse observe that correlates with a cognitive disorder?

deficit in memory

A client experiences polydipsia and voiding large amounts of waterlike urine with a specific gravity of 1.003. What do these clinical manifestations indicate to the nurse?

diabetes insipidus

A nurse collecting data on a post-craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output?

diabetes insipidus

A nurse cares for a client that reports sexual dysfunction. Which condition should the nurse consider as one of the most common causes of sexual dysfunction?

diabetes mellitus

An older adult client has a wound that is not healing normally. What factor should the nurse consider for the nonhealing wound?

diminished immune function interfering with ability to fight infection

A nurse is removing an indwelling urinary catheter. Which nursing action reflects the best technique?

document the time of removal

The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?

dry, cracked lips, strawberry tongue

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

encourage increased oral fluid intake

The nurse is caring for a client who has undergone an open surgical procedure for hiatal hernia repair. Which nursing intervention is a priority?

encouraging incentive spirometer use

A client with a diagnosis of borderline personality disorder is admitted to the unit after slashing their wrist. When assisting with the planning of care, which goal is most appropriate for this client?

establish a therapeutic relationship with the client

The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:

establish unresponsiveness.

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?

frequent respiratory infections

The nurse is caring for a geriatric client with a history of falls. While evaluating the client's risk of fall, the nurse should collect:

gait and balance information.

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on time spent in bed during the day.

A client with schizophrenia approaches a nurse and states, "I hear voices telling me that you are evil and deserve to die." The nurse interprets the client's statement as indicating which sign or symptom?

hallucination

While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. What does this finding suggest?

harlequin color change

A child diagnosed with leukemia is suspected to have metastasis to the brain. What symptoms observed by the nurse will correlate with this suspicion?

headache and vomiting

The nurse is observing a normal cardiac rhythm strip obtained from an adult client. Which characteristic leads to this normal finding?

heart rate of 88 beats/minute

A nurse is transferring a client from a bed to a chair. Which action should the nurse take during client transfer?

help the client dangle the legs

The nurse is caring for a client with suspected parathyroid dysfunction. Which laboratory results support a diagnosis of primary hyperparathyroidism?

high parathyroid hormone and high calcium levels

The nurse is reinforcing education for a client with uric acid calculi. Which type of diet should the nurse inform the client to avoid?

high purine

When gathering data for a 2-year-old child with a history of muscular dystrophy, the nurse observes that the child's legs appear to be held together and the knees are touching. The nurse suspects contraction of which muscles?

hip adductors

The physician diagnoses type 1 diabetes in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe:

human insulin.

A client with diabetes delivers a 9-lb, 6-oz (4,250 g) neonate. The nurse should be alert for which condition in the neonate?

hypoglycemia

A nurse is receiving the chart of an adolescent client who has been admitted to the unit. When reading the progress notes above, the nurse sees a laboratory result that indicates a condition consistent with a diagnosis of bulimia nervosa. Which condition does the nurse suspect?

hypokalemia

Which combination of adverse effects should the nurse carefully monitor when administering IV insulin to a client diagnosed with diabetic ketoacidosis?

hypokalemia and hypoglycemia

A nurse determines that a client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which behavior observed by the nurse would indicate this is taking place?

improved self-esteem

The nurse is instructing unlicensed assistive personnel (UAP) on how to properly position a client who underwent total hip replacement. The nurse explains that the client's hip needs to be in which position?

in an abducted position

A nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, where in the eye should the nurse instill the eyedrops?

into the conjunctival sac

A client presents to the emergency department with weight gain, lethargy, and goiter. When reviewing laboratory values, in which major mineral would the nurse anticipate this client to be deficient?

iodine

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode?

jitteriness

During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:

joint abnormalities.

A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priority for the client?

learning to express feelings

The nurse is caring for a client diagnosed with leukemia who is going to have a chemotherapy treatment. Which test would the nurse expect to be done to evaluate the client's ability to metabolize chemotherapeutic agents?

liver function studies

A pregnant client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. The client has a history of hypertension during pregnancy. The nurse anticipates the administration of which medication?

magnesium sulfate

A nurse on the psychiatric unit is caring for a client with antisocial personality disorder. Which behavior is the nurse most likely to observe?

manipulation, shallowness, and the need for immediate gratification

A nurse is about to give a backrub to a client after a complete bed bath. How should the nurse proceed?

massage gently in areas directly over pressure points

A nurse prepares to care for a client who has just transferred from the emergency department to the medical-surgical floor. Which is the most effective action that the nurse should take to prevent microbial transmission?

meticulous hand hygiene

A nurse is caring for a neonate diagnosed with fetal alcohol syndrome (FAS). When gathering data on this neonate, which craniofacial change would the nurse most likely find?

microcephaly

The nurse is providing care to a client with appendicitis. Which priority nursing intervention should the nurse perform?

monitoring for signs of peritonitis

The nurse is caring for a client in the immediate postoperative phase after undergoing gastric surgery. Which is the priority action by the nurse?

monitoring for symptoms of hemorrhage

Which complementary therapy might calm a 4-year-old who has separation anxiety when the child's parents leave the hospital?

music therapy

A nurse who is part of the multidisciplinary team is assigned to care for four neonates and is reviewing each neonate's plan of care. The nurse would closely monitor which neonate considered to be at highest risk for developing hyperbilirubinemia?

neonate with ABO incompatibility

A client arrives at the emergency department after falling on ice outside of the senior citizens' housing facility and sustaining a right hip fracture. Which finding would be most important for the nurse to evaluate?

neurovascular compromise

A client who has chronic bronchitis has asked the nurse to identify things that will help to promote better oxygenation. Which of the following lifestyle factors does the nurse identify as affecting a client's oxygenation? Select all that apply.

nutrition physical exercise anxiety

A nurse is reinforcing discharge instructions to a client after treatment for a severe allergic reaction from a bee sting. What instructions should the nurse include? Select all that apply.

obtain diphenhydramine to take following a bee sting fill the prescription for injectable epinephrine to carry with you

A client has just returned from the postanesthesia care unit (PACU) after undergoing internal fixation of a left femoral neck fracture. The nurse should place the client in which position?

on the client's back with two pillows between the legs

Six months after the death of her infant son, a client is diagnosed with dysfunctional grieving. Which behavior would the nurse expect to find?

overactive without a sense of loss

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? Select all that apply.

pain management and comfort measures parental support enabling the parents to participate in the infant's care

An emergency department nurse suspects neglect in a 3-year-old child admitted for failure to thrive. What behavior in the child should the nurse look for that might indicate signs of neglect?

poor hygiene and weight loss

A nurse is obtaining data from a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?

positive Kernig's sign

A client is admitted to the cardiac unit with a diagnosis of heart failure. The health care provider prescribes furosemide and digoxin to manage the condition. Which laboratory value should be monitored during hospitalization?

potassium

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action?

pouring solution directly onto a sterile field barrier

A client with pregnancy-induced hypertension (PIH) is admitted to the hospital. The nurse would expect this client to probably exhibit which of the following symptoms?

proteinuria, headaches, and double vision

A client whose gestational diabetes is poorly controlled throughout her pregnancy goes into labor at 38 weeks' gestation and gives birth. When assisting with implementing the plan of care for this neonate, which intervention would be the priority during the neonate's first 24 hours?

providing frequent early feedings with formula

A nurse is caring for a neonate with congenital hypothyroidism. Which data should the nurse anticipate ?

puffy eyelids

A client is suspected of having a pulmonary embolus. Which test should the nurse prepare the client for that is definitive?

pulmonary angiogram

A client comes to the emergency department with status asthmaticus. Based on the documentation note shown, the nurse suspects that the client has what abnormality?

respiratory alkalosis

After reviewing the client's maternal history of receiving magnesium sulfate during labor, which condition should the nurse anticipate as a potential problem in the neonate?

respiratory depression

A client who wanders is admitted to a restraint-free facility. Which nursing interventions can be implemented to avoid restraint use? Select all that apply.

schedule diversional activities take client on daily walks place client in a room close to the nurses' station

A 59-year-old client is scheduled for cardiac catheterization the next morning. His physician prescribed secobarbital sodium, 100 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that:

sedatives reduce excitement; hypnotics induce sleep.

The nurse is providing care to a pregnant client with preeclampsia. Magnesium sulfate has been ordered. The nurse understands that this drug is being given to prevent which condition?

seizures

The nurse is reviewing client documentation before receiving shift report. After reading the selection shown, for which stage of labor will the nurse plan upcoming care for the client?

stage 1, active phase

During data collection of a newly admitted client, the nurse observes a reddened area on the left heel. The nurse applies pressure to the reddened area and notes that it does not blanch when pressure is relieved. When documenting the findings, which appropriate stage would the nurse assign to this pressure sore?

stage I

A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?

stimulates labor and prevents hemorrhage

A nurse wants to use a waist restraint for a client who wanders at night. Which intervention should be considered before applying the restraint?

the client's reason for getting out of bed

A client returns to the acute care unit after abdominal surgery. Which measure should the nurse perform first that will help reduce or prevent the incidence of atelectasis?

use of an incentive spirometer

The nurse is assisting with a care plan for a client admitted with Alzheimer's dementia. The family reports that the client has to be watched closely for wandering behavior at night. Which nursing action will be of the greatest importance?

using a bed check monitor device

The nurse is caring for a client at risk for skin impairment. Which intervention is best to decrease this client's risk?

using a specialty mattress

A client who has difficulty sleeping is asked to keep a sleep diary. Which information should the nurse instruct the client to keep in this diary?

usual bedtime

Which finding would concern the nurse who's caring for an infant after a right femoral cardiac catheterization?

weak right dorsalis pedis pulse

A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type I diabetes mellitus and admits the child to the facility for insulin regulation. The physician prescribes an insulin regimen of insulin (Humulin R) and isophane insulin (Humulin N) administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act?

½ to 1 hour