U-World (All Questions)

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A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? 1. Gastrointestinal bleeding 2. Growth retardation 3. Neurocognitive impairment 4. Severe liver injury

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul-smelling stools 3. Stools mixed with blood and mucus 4. Thin, "ribbon-like" stools

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? 1. Administer oxygen via nasal cannula for client comfort and safety 2. Clean area with povidone iodine in a circular motion moving outward 3. Hold the child with the head and knees tucked in and the back rounded out 4. Monitor and record vital signs every 15 minutes throughout the procedure

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately

The nurse cares for a 4-year-old who is on long-term, strict bed rest. Which toy is most appropriate to provide diversion and minimize developmental delays? 1. Board games 2. Puppets 3. Soap bubbles 4. Stacking and nesting toys

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? 1. Eye drops in the abnormal eye 2. Measurement of intraocular pressure (IOP) 3. Patching the stronger eye 4. Correction with laser surgery

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply.

A,B,D

The nurse is preparing to administer 40 m of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters?

A,B,D

The home health nurse visits a 75 yr old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect?

A,B,D,E

Which findings support a diagnosis post-traumatic stress disorder? Select all that apply

A,B,D,E

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority? 1. Blood pressure 2. Hematuria 3. Intake and output 4. Peripheral edema

Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

A,B,D,E

A nurse is caring for a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to report to the registered nurse? 1. Bilateral pitting edema in ankles 2. Blood pressure is 140/88 mm Hg 3. Most recent HbA1c is 6.7% 4. Retinal photocoagulation in right eye

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply.

A,B,D,F

A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse? 1. Encourage the parent to be involved with the child 2. Engage in physical contact by removing the toddler's outer clothing first 3. Have medical equipment lying on a counter within view 4. Perform an examination in a head-to-toe order

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine. The health care provider prescribes 0.1 mg naloxone IM to be given STAT once. The client weight 3600 grams and maxalone .4 mg is available. How many milliliters will the nurse administer?

0.9

A child in the emergency department had a cast placed on the right arm for a nondisplaced fracture. The client is being discharged home with pain medications. Which statement by the parent indicates that additional teaching is required? 1. "A tingling or burning sensation within the first 24-48 hours is not a concern." 2. "An itching sensation under the cast for the first 24-48 hours is not a concern." 3. "I will call the doctor if pain is severe despite medications for the first 24 hours." 4. "My child should elevate the arm for the first 24-48 hours."

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity 2. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze 3. Place the tooth in water and transport the client to the nearest emergency department 4. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment

A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider? 1. Client excitedly reports being able to go an entire work day without having to urinate 2. Client is using an over-the-counter artificial saliva product for dry mouth 3. Client reports occasional dizziness in the morning and when changing positions 4. Client reports symptoms of constipation

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider? 1. Diarrhea, vomiting, and mild tremor 2. Dry mouth and mild thirst 3. Hyperactivity and auditory hallucinations 4. Lithium level of 1.3 mEq/L (1.3 mmol/L)

A client in the emergency department is being discharged with a prescription for trimethoprim-sulfamethoxazole. Which statement by the client would indicate a need for further evaluation? 1. "I developed a whole-body rash while on glyburide." 2. "I drink at least 5 large bottles of water daily." 3. "I had to stop using lisinopril due to a bad cough." 4. "I have a birth control implant in place."

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage

A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use? 1. Clostridium difficile infection 2. Gait disturbance 3. Jaw necrosis 4. Tremor

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1. Bumetanide 2. Candesartan 3. Carvedilol 4. Isosorbide

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? 1. Administer rectal diazepam 2. Assess for neck stiffness and Brudzinski sign 3. Draw blood for laboratory studies 4. Transport the client to CT for assessment of shunt malfunction

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1. Blurred vision 2. Dark-colored urine 3. Difficulty hearing 4. Yellow skin

A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? 1. "I have started taking a daily multivitamin with my dinner-time dose of medication." 2. "I may have oily stools and fecal incontinence when taking this medication." 3. "I will consume a low-fat diet in which no more than 30% of my calories are from fat." 4. "I will take my medication with, or within 1 hour of, meals that contain fat."

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse most likely to observe? 1. Choking and cyanosis during feeding 2. Concave (scaphoid) abdomen 3. Diminished lung sounds 4. Projectile vomiting after feeding

A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review? 1. "Give acetaminophen or ibuprofen every 6-8 hours to control fever." 2. "Give the infant frequent tepid sponge baths to control the fever." 3. "If the infant develops another seizure, wait 15 minutes to see if it subsides." 4. "Place ice bags under the arms and around the neck to control fever."

A parent rushes a 4-year-old to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. The child is sniffling and crying quietly. The practical nurse anticipates initially assisting with the implementation of which treatment? 1. Activated charcoal 2. Gastric lavage 3. Sodium bicarbonate 4. Syrup of ipecac

An adolescent client with a sore throat is diagnosed with infectious mononucleosis. Which comment by the caregiver would alert the nurse that additional instruction is necessary? 1. "I need to go to the pharmacy to pick up an antibiotic prescription." 2. "It is acceptable for my child to have ibuprofen for discomfort or fever." 3. "My child will be on bed rest with few activities for the next 2 weeks." 4. "Participation in soccer practice will not be allowed for the next month."

The 11:00 AM routine fingerstick (glucose monitoring) test for a client was assigned to the unlicensed assistive personnel by the nurse. At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first? 1. Ask the unlicensed assistive personnel (UAP) about the situation 2. Inform the nurse manager 3. Perform the test 4. Review the fingerstick procedure with the UAP

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis? 1. Anal itching that is worse at night 2. Intestinal bleeding with anemia 3. Poor appetite with weight loss 4. Red, scaly, blistered rings on skin

The clinic nurse is reviewing self-care management of acne vulgaris with an adolescent client. Which client statement indicates a need for further instruction? 1. "I have been scrubbing my face twice daily with antibacterial soap." 2. "I should buy skin care products that are labeled noncomedogenic." 3. "Maintaining a nutritious diet will help my skin heal." 4. "Picking or squeezing the lesions will worsen my acne."

The health care provider (HCP) prescribes a 10-day course of amoxicillin for a 1-year-old diagnosed with acute otitis media (AOM). Which instruction is most important for the nurse to review with the child's parents? 1. Return to the office if the child does not improve within 48-72 hours 2. Stop the antibiotic if the child develops diarrhea 3. Stop the antibiotic if the child feels better after 72 hours 4. Use over-the-counter decongestants to help with recovery

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver? 1. Administer the medication around the clock even if the client denies having pain 2. Avoid administering with immediate-release opioids to prevent respiratory depression 3. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs 4. Request a tapered dose from the health care provider if pain decreases to prevent tolerance

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask? 1. "Are you taking any over-the-counter medicines for your cold?" 2. "Are you taking extra vitamin C?" 3. "Did you babysit your granddaughter this past week?" 4. "Did you get a flu shot in the past week?"

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding 2. Absence of tears in crying child with IV start 3. Blood-streaked mucous stool in diaper 4. Sausage-shaped right-sided mass on palpation

The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention? 1. A 2-year-old eating a hot dog unsupervised 2. A 3-year-old playing alone in a wading pool 3. A 4-year-old tossing a beach ball 4. A 5-year-old climbing on monkey bars

The nurse is collecting data on the psychosocial development of a 2-year-old. What is the priority finding that should be reported to the supervising registered nurse? 1. Does not talk or respond when spoken or read to 2. Likes to imitate others by playing house and talking on the telephone 3. Refuses to go to sleep without a particular stuffed animal and a bedtime story 4. Says "no" to everything and has temper tantrums

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. 1. Furosemide 2. Glipizide 3. Levofloxacin 4. Potassium chloride

The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment with the health care provider? 1. Client with bronchospasm who is due to receive nebulized acetylcysteine 2. Client with chronic obstructive pulmonary disease due to receive PO prednisone 3. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast 4. Client with suspected bacterial pneumonia due to receive IV levofloxacin

The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care? 1. Discuss the procedure with the client using simple diagrams with correct anatomical terminology 2. Explore the client's perception of how the surgery will positively affect their future 3. Focus primarily on the client's feelings and concerns regarding surgical scar appearance 4. Provide initial education about the procedure to the client immediately before it is performed

A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.

A,B,E

The nurse is reinforcing discharge instructions for the parents of a 4-year-old with heart failure. Which statement by one of the parents indicates the need for further teaching related to digoxin administration? 1. "We will hold the dose if our child's heart rate is above 90/min." 2. "We will not give a second dose if our child vomits after the first dose." 3. "We will not mix the medication with other foods or liquids." 4. "We will report symptoms of nausea and vomiting to our health care provider."

The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Joint pain 4. Skin peeling

The nurse is reinforcing education to the parents of an adopted 5-year-old about how best to share details of the child's adoption. Which developmentally appropriate thought process does the nurse counsel the parents to anticipate? 1. Feelings of responsibility for being placed for adoption 2. Imagining what life would be like with a different family 3. Inability to conceptualize adoptive and biological parents 4. Worrying about what peers will say or think

The nurse is reinforcing instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach." 2. "I plan to eat more fruits and vegetables to prevent constipation." 3. "I should not drive until I know how this drug affects me." 4. "I will drink at least 6-8 glasses of water daily."

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." 2. "I will immediately change the tracheostomy tube if my child has difficulty breathing." 3. "I will provide deep suctioning frequently to prevent any airway obstruction." 4. "I will remove the humidifier if my child starts developing more secretions."

The nurse is reviewing teaching with the parents of a child who has tinea capitis (ringworm of the scalp) and is newly prescribed griseofulvin oral suspension and 1% selenium sulfide shampoo. Which statement by the child's parent requires the nurse to intervene? 1. "I will discontinue the griseofulvin once the ringworm stops itching and the scales go away." 2. "I will give the griseofulvin suspension to my child after consumption of high-fat food, like ice cream." 3. "I will monitor my child for increased sensitivity to sunlight while taking griseofulvin." 4. "I will wash my child's scalp a few times per week with the medicated shampoo."

The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel? 1. Check the blood glucose before meals and report it to the nurse 2. Instruct the client to cut toenails straight across and file any sharp edges 3. Monitor the client for signs and symptoms of hypoglycemia 4. Update the care plan to include client's preference for a nighttime diabetic snack

The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the health care provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L)

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? 1. Client's respiratory status 60 minutes later 2. Documenting the client's hypoxic event 3. Obtaining an order for a different analgesic 4. Potential for drug-drug interaction now

The registered nurse (RN) teaches the parents of a hospitalized 3-month-old about separation anxiety. The practical nurse notices that the parents still seem concerned about leaving the infant while they work and so reinforces the information provided by the RN. Which statement by one of the parents indicates that the teaching has been effective? 1. "At this age, my baby will not cry because we are leaving." 2. "I know my baby will feel abandoned when we leave." 3. "My baby is too young to sense my anxiety about leaving." 4. "My baby understands that we will return later in the day."

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? 1. Bladder scan showing 500 mL urine 2. Hemoglobin of 11 g/dL (110 g/L) 3. History of cataracts 4. Reporting frequent diarrhea today

The nurse is reinforcing education to a group of parents about ways to decrease the risk of sudden infant death syndrome. Which of the following recommendations should the nurse suggest? Select all that apply. 1. Breastfeeding the infant 2. Cosleeping with the infant in the parent's bed 3. Giving the infant a pacifier at bedtime 4. Maintaining a smoke-free environment 5. Placing the infant to sleep in a side-lying position

1,3,4

The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply. 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation

1,3,4

The nurse assists with a staff education conference about appropriate nonpharmacological pain-management interventions for newborns and infants. Which of the following strategies should be included in the presentation? Select all that apply. 1. Administer an oral sucrose solution to a newborn during a circumcision procedure 2. Apply a cold pack to a newborn's heel 30 minutes before performing a heel stick 3. Assist the parent to hold a newborn skin-to-skin during an immunization injection 4. Offer a pacifier to an infant while performing venipuncture 5. Swaddle an infant while leaving one arm unwrapped during an IV dressing change

1,3,4,5

A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age? Select all that apply. 1. Grasps a small doll by the arm 2. Stacks 3 wooden blocks 3. Transfers small objects from hand to hand 4. Turns single pages in a book 5. Uses a basic pincer grasp

1,3,5

A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions does the nurse anticipate for this client? Select all that apply. 1. Cluster care to limit each staff member's time in the room to 30 minutes a shift 2. Instruct the client to be up and around in the room but not to leave the room 3. Place a sign on the client's door stating "Caution, Radioactive Material" 4. Remind family members and visitors to stay at least 6 ft (1.82 m) away from the client 5. Use a lead apron when providing direct client care to reduce exposure to radiation 6. Wear a radiation film badge while in the client's room to monitor radiation exposure

1,3,4,5,6

A nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply. 1. Behavior appears withdrawn 2. Intelligible speech began at age 12 months 3. Monotone speech 4. Seems attentive, nods, and smiles when given directions 5. Speaks with a loud voice

1,3,5

Which are appropriate examples of cost-effective care? Select all that apply.

1,2

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply.

1,2,3

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerin patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value

1,2,3

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply. 1. Apical heart rate of 88/min 2. Elevation of mood 3. Improved energy levels 4. Skin is cool and dry 5. Slight weight gain

1,2,3

The nurse is caring for a client with moderate asthma exacerbation. Which of the following assigned tasks are within the practical nurse's scope of practice? Select all that apply.

1,2,3

The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply. 1. Apply a cold cloth to the bridge of the nose 2. Apply pressure by pinching the nostrils together 3. Attempt to keep the child calm and quiet 4. Have the child lie down and turn to the left side 5. Take the child to the emergency department

1,2,3

The practical nurse is assisting the registered nurse to create a care plan for a 3-year-old client admitted with a pertussis infection. Which of the following interventions should be included? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small sips of fluid frequently 4. Place client in a negative-pressure isolation room 5. Request a prescription for cough suppressants

1,2,3

Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? Select all that apply. 1. Frequent pulling on the affected ear 2. Refusal to eat 3. Restlessness and irritability 4. Retracted tympanic membranes 5. Severe pain with pressure on the tragus

1,2,3

The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply. 1. Encourage small, frequent feedings 2. Offer a pacifier when the infant begins to cry 3. Promote quiet time on waking in the morning 4. Swaddle the infant during procedures 5. Turn the infant frequently during sleep

1,2,3,4

The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply. 1. Allow the child to play with the stethoscope 2. Begin with the child in the parent's lap 3. Interact with the parent in a friendly manner 4. Play with the child using a finger puppet 5. Start by taking the child's vital signs

1,2,3,4

A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action? 1. Administer 100% oxygen 2. Auscultate the lungs 3. Place infant in knee-chest position 4. Suction the infant's mouth

1,2,4

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awaken 2. Dry skin 3. Frequent, loose stools 4. Hoarse cry 5. Tachycardia

1,2,4

A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply. 1. "I should have our home inspected for the source of lead." 2. "I will vacuum our hard-surface floors daily." 3. "I will wash my child's hands often, especially before eating." 4. "We should use hot water from the tap for cooking." 5. "We will have to return for a follow-up lead level."

1,3,5

A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply. 1. Chronic hypoxemia 2. Diabetes insipidus 3. Frequent respiratory infections 4. Obesity 5. Vitamin deficiencies

1,3,5

A nurse is caring for a school-age client with fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which of the following interventions should the nurse plan to implement for this client? Select all that apply. 1. Elevate head of bed at 30 degrees 2. Implement seizure precautions 3. Keep a mask on the client at all times 4. Minimize environmental stimuli 5. Place client in a room with negative-pressure air flow OmittedCorrect answer 1,2,4 34%Answered correctly 01 secTime Spent 09/13/2020Last Updated Explanation Bacterial meningitis is an infection that causes inflammation of the membranes covering the brain and spinal cord (ie, meninges). Inflammation and bacterial growth within the meninges lead to increased cerebrospinal fluid (CSF) volume and increased intracranial pressure (ICP). Without intervention, increased ICP may lead to nerve ischemia and permanent functional impairment (eg, hearing loss, visual impairment, paralysis), brain herniation, or death. The nurse should perform the following interventions: Maintain the head of the bed elevated at 30 degrees with the head and neck midline to reduce ICP by promoting drainage of cerebral venous blood and CSF (Option 1) Implement seizure precautions due to potential neurologic irritability from increased ICP (Option 2) Ensure a restful environment (eg, quiet, dimly lit, cool temperature) by reducing potentially irritable stimuli (Option 4) (Option 3) The nurse should initiate droplet precautions for clients with meningococcal meningitis that require the nurse (not the client) to wear a mask when caring for the client. The client wears a mask only if being transported outside the room. (Option 5) A negative-pressure air flow room is appropriate for a client requiring airborne precautions (eg, active tuberculosis). Educational objective:Nursing care for a client with suspected meningococcal meningitis includes elevating the head of the bed at 30 degrees, implementing seizure precautions, and minimizing environmental stimuli. The nurse should implement droplet precautions that require the nurse (not the client) to wear a mask when caring for the client. The client wears the mask only if transported outside the room. Additional Information Physiological Adaptation NCSBN Client Need Copyright © UWorld. All rights reserved.

1,2,4

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1. Haemophilus influenzae type b (Hib) 2. Hepatitis A (Hep A) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate vaccine (PCV) 5. Varicella

1,2,4

The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply. 1. Administer the medication with food if nausea or diarrhea develops 2. Complete the medication course even if the child is better 3. Rash is a normal, expected side effect 4. Shake the medicine well before use 5. Use a household spoon to measure the dose

1,2,4

The nurse is reviewing anticipatory guidance with the parents of a 6-month-old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply. 1. "A low-phenylalanine diet is required." 2. "Meat and dairy products should not be introduced into the diet." 3. "Phenylketonuria is self-limiting and usually resolves by adulthood." 4. "Special infant formula is required." 5. "Tyrosine should be removed from the diet."

1,2,4

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply. 1. Encourage the parents to leave the child's favorite stuffed animal 2. Establish a daily schedule similar to the child's home routine 3. Give the child time to calm down alone when visibly upset 4. Provide frequent opportunities for play and activity 5. Remove visual reminders of the parents from the room

1,2,4

The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply. 1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement 2. Advises the client transport technician, "This client has fragile bones due to cancer, so move the client very carefully." 3. Asks a client, "When were you diagnosed with diabetes?" in a semi-private room with the privacy curtain in place between beds 4. Interprets the results of a client's diagnostic testing to the unit clerk 5. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged

1,2,4

Which discharge teaching instructions should the nurse reinforce to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply. 1. Complete all the antibiotics even if your child is feeling better 2. Cool liquids and soft diet are recommended 3. Keep your child home from daycare for at least a week 4. Replace your child's toothbrush 24 hours after starting antibiotics 5. Throat lozenges may soothe your child's sore throat

1,2,4

The nurse cares for a client who has oral candidiasis. The health care provider has prescribed nystatin oral suspension. Which of the following nursing actions are appropriate? Select all that apply. 1. Assist the client in removing dentures and soaking them in nystatin 2. Inspect the oral mucous membranes thoroughly before administering nystatin 3. Instruct the client to discontinue the medication as soon as symptoms subside 4. Instruct the client to swish the suspension in the mouth for several minutes 5. Shake the bottle of suspension thoroughly before measuring the dose

1,2,4,5

Which tasks can the licensed practical nurse appropriately assign to unlicensed assistive personnel? Select all that apply.

1,2,4,5

The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply. 1. Administration of oxygen 2. Administration of a 2nd dose of naloxone 3. Discontinuation of pain medication 4. Initiation of a rapid response or code team 5. Monitoring of respiratory rate

1,2,5

The nurse is reinforcing home care instructions for the parents of a child diagnosed with rotavirus infection. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1. "Hand washing is extremely important in slowing the spread of rotavirus." 2. "I will observe my child for decreased urination and dry mucous membranes." 3. "I will resume breastfeeding as soon as the diarrhea subsides." 4. "I will use commercial baby wipes that contain alcohol." 5. "My child can spread the infection with contaminated hands, toys, and food."

1,2,5

A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. 1. Albuterol 2. Ibuprofen 3. Ipratropium 4. Montelukast 5. Tobramycin

1,3

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply.

1,3

A nurse preceptor on a pediatric unit is reviewing interventions with a student nurse who will be caring for a toddler. What are appropriate activities to minimize the effect of hospitalization on a toddler? Select all that apply. 1. Integrate preferred snack foods in the day's routine 2. Explain the body changes that may occur 3. Plan quiet play prior to usual nap time 4. Post a daily schedule by the child's bed 5. Provide 1 or 2 options when choosing toys

1,3,5

The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply. 1. Consult the health care provider (HCP) if you experience leg pain or swelling 2. Discontinue contraceptives if you experience spotting between menses 3. Do not smoke while taking combined contraceptives 4. Immediately report any breast tenderness to the HCP 5. Seek immediate medical treatment if you experience vision loss

1,3,5

Which medication prescriptions should the nurse question? Select all that apply. 1. Cephalexin for a client with severe allergy to penicillin 2. Fexofenadine for a client with hives 3. Ibuprofen for a client with asthma and nasal polyps 4. Lisinopril for a client with diabetes mellitus 5. Propranolol for a client with asthma

1,3,5

A nurse is reinforcing teaching to a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. 1. "Antibiotics can affect my INR value." 2. "I am going to eat more leafy greens." 3. "I will shoot for my INR value to be between 4 and 5." 4. "I will take warfarin at the same time daily." 5. "If I miss a dose, I can double it on the following day."

1,4

The nurse is evaluating client safety. Which actions by unlicensed assistive personnel would require the nurse to intervene? Select all that apply.

1,4

The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply. 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate (for a gastric ulcer) after meals to minimize gastric irritation 4. When taking ethambutol, notify the health care provider (HCP) for changes in vision 5. When taking rifampin, notify the HCP if the urine turns red-orange in color

1,4

Which client condition is concerning and requires further nursing observation and intervention? Select all that apply.

1,4

Which of the following are violations of the Health Insurance Portability and Accountability Act regarding confidentiality of privileged health information? Select all that apply. 1. A pregnancy result is given to a husband without the wife's permission 2. The client overhears, through a privacy curtain, the nurse call report on someone 3. The nurse calls the client by first and last name in the public waiting room 4. The nurse tells the transporting tech that the client has breast cancer 5. Unlicensed assistive personnel tell the discharged client, "You take care now."

1,4

A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Select all that apply. Click on the exhibit button for additional information. 1. Dryness of the mouth and throat may occur 2. Ringing in the ears is an expected, transient side effect 3. The albuterol canister should not be shaken before use 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed

1,4,5

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply. 1. Not taking tetracycline with dairy products 2. Taking tetracycline at bedtime 3. Taking tetracycline with food 4. Using additional contraceptive techniques 5. Using sunblock

1,4,5

The nurse assessing a 2-year-old should expect the child to be able to perform which actions? Select all that apply. 1. Build a tower with blocks 2. Draw a square 3. Hop on one foot 4. Say own name 5. Walk without help

1,4,5

The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply. 1. Advising measles vaccination for susceptible family members 2. Applying calamine lotion to reduce itching 3. Placing a tracheostomy tray at the bedside 4. Placing the client in a negative-pressure isolation room 5. Using an N95 respirator mask during client contact

1,4,5

The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply. 1. Excess blinking of eyes 2. Dry mouth 3. Dull headache 4. Lip smacking 5. Puffing of cheeks

1,4,5

The registered nurse delegates actions related to the care of colostomies to the practical nurse. Which actions should the practical nurse question as being outside the licensed practical nurse's scope of practice? Select all that apply.

1,4,5

Which statements related to ethical nursing practices are correct?

1,4,5

While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Reapply pneumatic compression device after bathing the client 5. Remind the client to use the incentive spirometer

1,4,5

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used.

1,4,5,3,2

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction of dizziness with standing

The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? Select all that apply. 1. "A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator." 2. "Depth of chest compressions for infants should be half the depth of the anterior-posterior chest diameter." 3. "Rescuers should place the heel of one hand on the lower sternum when delivering chest compressions to infants." 4. "The ratio of chest compressions to breaths during CPR by a single rescuer is 15:2 for infants." 5. "You should assess the infant's brachial pulse for no longer than 10 seconds."

1,5

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply. 1. Accepting a birthday gift of a gold bracelet from a client 2. Making a visit to the hospital after a client has surgery 3. Offering to pray together if a client so wishes 4. Sending a sympathy card to family after a client dies 5. Soliciting a wealthy client to invest in a company 6. Staying after work hours and drinking wine with a client

1,5,6

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the client's Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially? 1. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP) 2. Let UAP complete assigned tasks and speak to them at the end of the shift 3. Praise UAP for encouraging the client to walk the entire hallway 4. Speak with the nurse manager about the need for UAP inservice education

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action? 1. Assess the client's orthostatic blood pressure 2. Assist the client to a sitting position 3. Hold and walk with the client 4. Keep the client on bed rest

The nurse reinforces medication teaching to a client prescribed metronidazole. Which client statement indicates a need for further education? 1. "I might have a metallic taste in my mouth when I'm taking this medicine." 2. "I need to decrease the amount of alcohol I drink while taking this medicine." 3. "I should not worry if my urine turns a dark color while taking this medication." 4. "I will immediately call the clinic if I get a new rash or have skin peeling."

The nurse reinforcing teaching to the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? 1. Gluten-free with added protein 2. High calorie, high protein, high fat 3. High protein, low fat, low phosphate 4. High protein, low fat, low sodium

A practical nurse is evaluating the external fetal monitoring strip of a laboring primigravida who is at 36 weeks gestation. Which nursing interventions should the practical nurse anticipate?

A,B,E

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When considering the client's advance care planning needs, which topics should the nurse discuss? Select all that apply. 1. Financial power of attorney 2. Health care proxy 3. Life insurance beneficiary 4. Living will 5. Safe deposit box

2,4

The clinic nurse supervises a student nurse who is preparing to administer routine vaccinations to a child diagnosed with hemophilia. Which instructions should the clinic nurse provide to the student? Select all that apply. 1. Administer ibuprofen for pain relief 2. Administer vaccines via the subcutaneous route 3. Apply a warm compress to the injection site 4. Hold firm pressure on the site for 5 minutes 5. Massage the injection site to disperse the medication

2,4

A nurse is performing an assessment of a 12-month-old child. Which of the following findings would the nurse expect? Select all that apply. 1. Approaches strangers with ease 2. Birth weight is tripled 3. Can skip and hop on one foot 4. Fully developed pincer grasp 5. Sits from a standing position

2,4,5

The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply. 1. Palpable olive-shaped mass in epigastrium 2. Palpable sausage-shaped mass in upper right quadrant 3. Projectile vomiting containing blood 4. Screaming and drawing the knees up to the chest 5. Stool mixed with blood and mucus

2,4,5

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan

2,4,5

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.

2,4,5

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive "another pain pill." The nurse reviews the medication administration record. Which intervention should the nurse implement? Click on the exhibit button for additional information. 1. Administer the hydrocodone/acetaminophen as prescribed 2. Call the health care provider to request a prescription for a different analgesic 3. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1 4. Prepare to administer naloxone

The labor and delivery nurse is conducting a staff education conference on preterm labor management for clients <34 weeks gestation. Which of the following statements by a participant are appropriate?

A,B,E

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle 2. Check blood pressure prior to administering the erythropoietin 3. Hold the client's next scheduled iron sucrose dose 4. Hold the erythropoietin and inform the health care provider

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor."

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? 1. Evening primrose 2. Ginseng 3. Melatonin 4. St. John's wort

A client with asthma and sinusitis has increased wheezing and decreased peak flow readings. The nurse recognizes that which of the following over-the-counter home medications taken by the client could be contributing to increased asthma symptoms? 1. Guaifenesin 600 mg orally twice a day as needed 2. Ibuprofen 400 mg orally every 6 hours for pain as needed 3. Loratadine 1 tablet orally every day as needed 4. Vitamin D 2,000 units orally every day

A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? 1. "After taking this medication, I will rinse my mouth with water." 2. "At the first sign of an asthma attack, I will take this medication." 3. "I have been smoking for 12 years, but I just quit a month ago." 4. "I received the pneumococcal vaccine about a month ago."

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? 1. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." 2. "It can relieve your chronic pain and help you sleep better at night." 3. "It helps to relieve the adverse effects of your other prescribed drugs." 4. "You have the right to refuse. I will notify your health care provider (HCP)."

A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication? 1. Blood cultures 2. Creatinine levels 3. Magnesium levels 4. White blood cell (WBC) count

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse reinforce with this client? 1. Diet high in iron 2. Good oral care and dental follow-up 3. Shaving with an electric razor 4. Use of sunglasses for eye protection

Taking blood pressure medications as prescribed

134

The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number. Click on the exhibit button for additional information.

178

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? 1. "I should leave the harness on during diaper changes." 2. "I will adjust the harness straps every 3-5 days." 3. "I will inspect the skin under the straps 2-3 times daily." 4. "The harness should keep my baby's legs bent and spread apart."

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent monitoring of which of the following is most important? 1. Babinski reflex 2. Fontanel assessment 3. Pulse pressure 4. Pupillary light response

The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? 1. Need for an eye examination 2. Need for sunblock 3. Risk for infection 4. Risk for kidney injury

The nurse is caring for a child newly diagnosed with cystic fibrosis. What interventions does the nurse expect to be included in the clients multidisciplinary plan of care select all that apply.

A,B,E

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? 1. "I will let my child drink cocoa as usual the morning of the procedure." 2. "I will wash my child's hair using shampoo the morning of the procedure." 3. "My child may have scalp tenderness where the electrodes were applied." 4. "My child will not remember the procedure."

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? 1. Administer the prescribed pancrelipase 2. Hold the pancrelipase until the client eats 3. Notify the health care provider 4. Skip this dose of the pancrelipase

A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan? 1. Blood pressure measurements 2. Daily weight measurements 3. Severity of pitting edema 4. Strict intake and output measurements

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect? 1. Blood glucose of 95 mg/dL (5.3 mmol/L) 2. Potassium level of 4.2 mEq/L (4.2 mmol/L) 3. Reduction in dizziness 4. Sodium level of 138 mEq/L (138 mmol/L)

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the practical nurse (PN) to contact the supervising registered nurse (RN)? 1. Client reports numbness bilaterally since the surgery 2. Fondaparinux is prescribed for STAT administration 3. Lower-extremity muscle strength is 3/5 bilaterally 4. Postoperative laboratory results show hemoglobin of 9.9 g/dL

Administer prescribe me and I'll just take medication for incisional pain

124

High Fowlers

1245

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy? 1. "I won't need a bolus dose of insulin before my meals anymore." 2. "I'm glad my blood sugars won't go way up and way down, like they did before." 3. "I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore." 4. "It'll finally be easier for me to lose some weight."

A male client admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12 g/dL (120 g/L) is being prepared for surgery. Which prescription should the practical nurse validate with the registered nurse before administration? 1. Cefazolin 2. Enoxaparin 3. Morphine 4. Tetanus toxoid

A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? 1. Erectile dysfunction 2. Dizziness 3. Dry cough 4. Leg edema

A newborn has a large myelomeningocele. What nursing intervention is priority? 1. Assess the anus for muscle tone 2. Cover the area with a sterile, moist dressing 3. Measure the occipital frontal circumference 4. Place the newborn supine with the head of the bed elevated

A nurse in a pediatric clinic is collecting data on a 30-month-old child. Which finding requires further evaluation? 1. Bladder and bowel control achieved 2. Current weight is 6 times greater than birth weight 3. Head circumference increased by 1 in (2.5 cm) in the past year 4. Resting heart rate is 120 beats per minute

A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse? 1. "Take this in the morning 1 hour before breakfast." 2. "Take this with your other stomach medications." 3. "Take your heart medication 2 hours after sucralfate." 4. "You might experience constipation while taking this."

A nurse is reinforcing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? 1. Ear pain 2. Frequent swallowing 3. Low-grade fever 4. Objectionable mouth odor

A nurse is reinforcing teaching about herbal supplements to a group of clients in the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? 1. Clients diagnosed with heart failure 2. Clients with benign prostatic hyperplasia 3. Clients with major depressive disorder 4. Perimenopausal clients experiencing hot flashes

A nurse is talking with the parent of a 6-year-old regarding sleep and rest. Which information should be included? 1. Active play before bedtime promotes restful sleep 2. Bedtime hours should be established 3. Rest needs are related to the high rate of growth in this age group 4. Seven to 8 hours of sleep are required

A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause? Click the exhibit button for more information. 1. Captopril 2. Carvedilol 3. Glimepiride 4. Levothyroxine

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse? 1. Encourage the visitor to lie down to see if symptoms change 2. Initiate protocol to assist the visitor to the emergency department 3. Proceed to take the visitor's blood pressure 4. Suggest that the visitor call the health care provider

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? 1. Administer an analgesic 2. Assess the child's level of pain using a numeric rating scale 3. Come back later in the day 4. Tell the child, "Get up and walk if you want to go home soon."

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? 1. "I periodically take docusate sodium for constipation." 2. "I regularly take ibuprofen for chronic low back pain." 3. "I take hydrochlorothiazide to prevent swelling around my ankles." 4. "I take omeprazole daily to prevent heartburn."

NCLEX-PN TEST - Kehinde Balogun 00:07:39 48 of 85 0 A nurse is reinforcing teaching about herbal supplements to a group of clients in the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? 1. Clients diagnosed with heart failure 2. Clients with benign prostatic hyperplasia 3. Clients with major depressive disorder 4. Perimenopausal clients experiencing hot flashes

One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 µmol/L). Which action by the health care provider does the nurse anticipate? 1. Administer phenytoin as prescribed 2. Decrease phenytoin daily dose 3. Increase phenytoin daily dose 4. Repeat serum phenytoin level in 2 hours

The ambulatory care nurse is reassessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents ask how this could have been avoided. Which response by the nurse would be most appropriate? 1. "It's impossible to know for sure what could have caused this episode; please don't worry." 2. "Most cases of epiglottitis are preventable by standard childhood immunizations." 3. "There is nothing you could have done differently; the important thing is that your child is better." 4. "Why are you concerned? We are still waiting on the final report from the lab."

The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication? 1. "I can discontinue the medication if my symptoms improve." 2. "I need a healthy diet and regular exercise to combat weight gain." 3. "If I don't feel better in 1-2 weeks, then the medication is not working." 4. "This medication might increase my sexual performance."

The nurse caring for a client reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board 2. Document the exchange in the chart 3. Report the incident to the hospital's legal team 4. Report the incident to the state medical board

The nurse in an ambulatory care center is reinforcing teaching to a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? 1. "If I have a sudden change in my mood, I should call my physician immediately." 2. "If I have trouble swallowing the tablet, I can cut it in half." 3. "If I miss a dose, I should not double the next dose to catch up." 4. "It may take several weeks before I get better."

The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia? 1. Decreased right hip adduction 2. Presence of extra gluteal folds on right side 3. Right leg longer than the left leg 4. Right pelvic tilt with lordosis

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? 1. "I'll provide a healthy diet without added salt for my child." 2. "I'll organize playdates to keep my child's spirits up during relapses." 3. "I'll restrict my child's fluids if I notice swelling or rapid weight gain." 4. "I'll test for protein in my child's urine every day."

The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate? 1. "Omeprazole helps prevent nausea by making your stomach empty faster." 2. "Omeprazole helps prevent you from developing an ulcer due to the stress of surgery." 3. "Omeprazole protects you from getting an infection while on antibiotics." 4. "This medication will treat your gastroesophageal reflux disease (GERD)."

The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect? 1. Higher potassium level 2. Improved mental status 3. Looser stool consistency 4. Reduced abdominal distension

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur 2. Loud machine-like murmur 3. Soft diastolic murmur 4. Systolic ejection murmur

The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate? 1. Assign the same nurses and caregivers to the child each day 2. Avoid mentioning the loved one's death in the child's presence 3. Explain the importance of being with the child to the parents 4. Schedule time each day for age-appropriate play

The nurse is monitoring a client who has overdosed on alprazolam and alcohol. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benztropine 2. Flumazenil 3. Naloxone 4. Phentolamine

The nurse is observing the parent feed a 3-month-old diagnosed with gastroesophageal reflux. Which action by the parent indicates that further teaching is necessary? 1. The parent does not push the infant to finish the bottle 2. The parent engages the infant in active play after the feeding 3. The parent interrupts the feeding to burp the infant 4. The parent supports the infant upright during the feeding

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers? 1. Demonstrating adequate coping skills 2. Knowing how to keep blood sugars stable 3. Understanding how to perform meal planning 4. Understanding the need for periodic follow-up visits

The nurse is preparing medications scheduled at 8 AM for a client with type 1 diabetes mellitus. After reviewing the client's prescriptions and morning laboratory results, which action by the nurse is most appropriate? Click on the exhibit button for additional information. 1. Administer insulin lispro per protocol and 75 units NPH 2. Contact the health care provider 3. Obtain a urine specimen to check for ketonuria 4. Recheck the client's blood glucose

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

The nurse is reinforcing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? 1. "Our child should be feeling much better in 7-10 days." 2. "Our child's condition is communicable until the rash disappears." 3. "We will ensure our child covers the mouth and nose when coughing or sneezing." 4. "We will give our child ibuprofen to treat the joint pain."

The nurse is reinforcing teaching on behavioral strategies to treat fecal incontinence due to functional constipation to the parent of a 6-year-old. Which statement by the parent indicates a need for further teaching? 1. "I will give my child a picture book to look at during toilet time." 2. "I will give my child a reward for each bowel movement made while sitting on the toilet." 3. "I will keep a log of my child's bowel movements, laxative use, and episodes of soiling." 4. "I will schedule regular toilet sitting time for my child."

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) 2. Losartan for client with hypertension who is 8 weeks pregnant 3. Prednisone for client with herpes simplex lesions and Bell palsy 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease

The nurse reviews the medication administration records and laboratory results for assigned clients prior to drug administration. Which medication administration should the nurse question? 1. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L) 2. Clopidogrel for a client with a platelet count of 70,000/mm3 (70 × 109/L) 3. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) 4. Metformin for a client with a glycosylated hemoglobin level of 11%

The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful? 1. "Discipline your child by taking away playroom privileges." 2. "It is normal for your child to regress while hospitalized." 3. "Restricting fluids at nighttime will solve this problem." 4. "Your child is acting out due to the hospitalization."

The practical nurse is collaborating with the registered nurse to create a care plan for a child being admitted with Kawasaki disease. Which nursing intervention is the priority? 1. Apply cool compresses to the skin of the hands and feet 2. Monitor for a gallop heart rhythm and decreased urine output 3. Prepare a quiet, non-stimulating, and restful environment 4. Provide soft foods and liberal amounts of clear liquids

The practical nurse is conducting a hospital admission history and assessment in collaboration with the registered nurse. The client reports taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response? 1. Ask the client about menopausal symptoms 2. Contact the pharmacy to see if the herb interferes with the client's medications 3. Facilitate a prescription for use of the herb during hospitalization 4. Tell the client to stop taking the herb

The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? 1. Call the health care provider 2. Determine the client's peak expiratory flow 3. Notify the client's parents 4. Remind the client about avoiding triggers

The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply. 1. "Diets consisting of legumes as the only protein source are sufficient for growth." 2. "It is important to feed your child fortified breads and cereals to help with iron intake." 3. "Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake." 4. "Try to pair foods high in iron with foods high in vitamin C to aid iron absorption." 5. "Your child may require calcium and vitamin D supplementation due to lack of dairy intake."

2,4,5

The nurse is reinforcing education on child abuse and neglect to a certified home health aide. The nurse will include which statements in identifying the characteristics of the typical perpetrator of child abuse? Select all that apply

A,B,F

A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply. 1. 4-month-old client who is receiving scheduled vaccinations 2. 3-year-old client who is afraid of needles 3. 24-year-old client who is 6 weeks postpartum 4. 32-year-old client who is pregnant at 12 weeks gestation 5. 45-year-old client with a history of HIV

2,3

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.

2,3

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information. 1. Diltiazem extended-release PO 2. Heparin subcutaneous injection 3. Lisinopril PO 4. Metoprolol PO 5. Timolol ophthalmic

2,3

The nurse reinforces instructions to a client discharged on warfarin, after being treated for a pulmonary embolism following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply. 1. "I will need to take my blood thinner for about 3-6 months." 2. "I will place small rugs on my wood floors to cushion a fall." 3. "I will take a baby aspirin if I have mild chest pain." 4. "I will use a soft-bristled toothbrush to clean my teeth." 5. "I will wear a blood thinner MedicAlert tag."

2,3

The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs? Select all that apply. 1. Create a strict daily schedule for the client while hospitalized 2. Encourage the client to have peers visit while hospitalized 3. Ensure parental presence during any client procedure 4. Include the client as an active participant when planning care 5. Support the client in discussing concerns about body image changes

2,4,5

The practical nurse is assisting the registered nurse in creating a teaching plan for the parents of a child diagnosed with pediculosis capitis. Which instructions should be included in the teaching plan? Select all that apply. 1. It is not necessary to treat other children in the household 2. Soak the child's comb and hair accessories in boiling water for 10 minutes 3. The family pet will need treatment with a pediculicide 4. Use a nit comb daily for 2 weeks after pediculicide treatment 5. Vacuum the furniture, carpets, and mattresses every few days

2,4,5

A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply. 1. "Apply lotion under the straps to protect the skin." 2. "Dress the child in a shirt and knee socks under the straps." 3. "Lightly massage the skin under the straps daily." 4. "Place the diaper under the straps." 5. "Remove the harness during diaper changes."

2,3,4

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.

2,3,4

The nurse reinforces medication instructions to a client with primary adrenal insufficiency (Addison disease) who is prescribed hydrocortisone 10 mg orally 3 times a day. Which instructions should be included? Select all that apply. 1. Discontinue hydrocortisone if you have mood changes or disruptions in behavior 2. Make an appointment with an optometrist yearly to assess for cataracts 3. Report even a low-grade fever to the health care provider immediately 4. Report signs of hyperglycemia, including increased urine, hunger, and thirst 5. Take the medication on an empty stomach 6. The dose of hydrocortisone may need to be decreased during times of stress

2,3,4

What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply. 1. Both caregivers work outside the home 2. Infant lives only with mother, who is currently unemployed 3. Infant's primary caregiver has cognitive disabilities 4. Parents are socially and emotionally isolated 5. Parents live together but are not married

2,3,4

Which components are used in determining the standards of professional nursing practice? Select all that apply. 1. Care given with good intention to the best of one's ability 2. Clinical practice statements of professional organizations 3. Health care institution's policies and procedures 4. Nurse Practice Act of the state or province/territory 5. Nurse's usual custom and practice

2,3,4

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohosh 2. Garlic 3. Ginger 4. Ginkgo biloba 5. Hawthorn

2,3,4

A client who had a bowel resection 5 days ago The nurse finds the incision edges separated and bowel protruding through the wound. Which of the actions are appropriate

2,3,4,5

The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply. 1. "Apply the patch when the ship starts moving and not before." 2. "Dispose of the patch out of reach of children and pets." 3. "Ensure that the old patch is removed before applying a new one." 4. "Place the patch on a hairless, clean, dry area behind the ear." 5. "Wash your hands with soap and water after handling the patch."

2,3,4,5

The nurse is caring for a confused client in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.

2,3,4,5

The nurse is caring for a confused client in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply. 1. Assess circulation and sensation of the extremities 2. Perform range of motion exercises 3. Reapply the restraints after toileting 4. Report changes in skin integrity 5. Turn and reposition the client in bed

2,3,4,5

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply. 1. Depressed anterior fontanelle 2. Frequent seizures 3. High-pitched cry 4. Poor feeding 5. Presence of the Babinski sign 6. Vomiting

2,3,4,6

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refuses to feed

2,3,5

The nurse is reinforcing discharge teaching with a client who has been prescribed warfarin for chronic atrial fibrillation. The client should avoid excess or inconsistent intake of which foods? Select all that apply. 1. Bananas 2. Broccoli 3. Grapefruit juice 4. Red meat 5. Spinach

2,3,5

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply. 1. Child is the youngest of four children in the home 2. One parent is incarcerated for spousal abuse 3. One parent was diagnosed with anorexia nervosa prior to having children 4. One parent works a full-time job outside the home 5. Parents are concerned about not having enough money to buy food

2,3,5

The nurse is drawing from a clients peripheral vein for laboratory specimens. Which of the following are correct nursing actions?

A,C

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately? Select all that apply. 1. Albuterol 2. Doxycycline 3. Insulin as part 4. Isotretinoin 5. Levothyroxine 6. Lisinopril

2,4,6

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity

The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine

The nurse is monitoring a newborn. Which of the following clinical findings should the nurse recognize as expected? Select all that apply?

A,C

1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving."

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? 1. Close monitoring for hypotension 2. Gradually increasing the prednisone dose 3. Increasing the insulin dose 4. Monitoring and recording intake and output

A 15-year-old client with type 1 diabetes mellitus is admitted to the hospital with a blood glucose of 460 mg/dL (25.6 mmol/L). Based on this information, the nurse understands that which factor is contributing to this client's noncompliant behavior? 1. Client has limited understanding of the disease process 2. Client is depressed and wants to die 3. Client's psychosocial developmental stage 4. Lack of supervision by the client's caregivers

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply?

A,C,D

A 5-year-old child is receiving morphine sulfate for pain. Which statement by the caregiver indicates that further teaching is necessary? 1. "I will call the nurse if my child begins to act aggressively." 2. "I'm concerned that my child thinks the pain is punishment." 3. "My child is playing and so does not need pain medication." 4. "The FACES pain scale seems to be working very well."

A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following? 1. Brown-colored urine 2. Hearing and balance problems 3. Pain in the Achilles tendon area 4. Sunburn

The nurse is reinforcing teaching to a client diagnosed with raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include. Select all that apply?

A,C,D,E

Which actions by a nurse are reportable to the state board of nursing?

A,C,D,E

Which of the following drug administrations should be reported as a practice error?

A,C,E

A nurse is discussing parallel play with the parent of a 2-year-old. Which statement by the parent indicates understanding of the discussion? 1. "I encourage working in a group to build towers with large blocks." 2. "I have a chalk board available to teach the alphabet and numbers." 3. "I set out a basket of various balls in the backyard when other children come to play." 4. "I try to organize games that involve a team approach."

A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning and should be reported to the registered nurse? 1. "I like to have a banana every morning with breakfast." 2. "I occasionally experience slight dizziness when I get up in the morning." 3. "I started taking licorice root for occasional heartburn." 4. "I usually take my hydrochlorothiazide first thing in the morning."

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure? 1. Abdominal rigidity and diarrhea 2. Back pain and urge incontinence 3. Difficulty swallowing and breathing 4. Difficulty walking and hand tremor

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x 1

A client with atrial fibrillation has just been placed on warfarin therapy. The nurse preceptor overhears the student nurse reinforcing teaching to the client about potential food-drug interactions. Which statement made by the student nurse requires the nurse preceptor to intervene? 1. "Do you take any nutritional supplements?" 2. "You will need to monitor your intake of foods containing vitamin K." 3. "You will not be able to eat green leafy vegetables while taking warfarin." 4. "Your blood will be tested at regular intervals."

A nurse is planning to test the visual acuity of a 7-year-old. Which is the best way to test visual acuity in this child? 1. Have the child focus on a bright object and follow the target 2. Have the child view a set of cards one at a time 3. Position the child at a distance of 10 ft (3 m) from a chart 4. Shine a light into the child's eyes at a distance of 16 in (40.6 cm)

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has reinforced discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out." 2. "I can still take this with my vardenafil prescription." 3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 4. "I should stop taking the pills if I experience a headache."

A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to this client about which possible side effect? 1. Constipation 2. Sedation 3. Sexual dysfunction 4. Weight loss

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up? 1. Also takes ibuprofen for pain 2. Frequency of urination has increased 3. Mild red rash has developed over torso 4. Nausea occurs after each dose

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function laboratory results 2. Flush tube with normal saline, not water 3. Stop the feeding for 1 to 2 hours 4. Take the blood pressure (BP)

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to reinforce with this client? 1. Avoid consuming high-sodium foods 2. Change positions slowly to prevent dizziness 3. Don't stop taking this medication abruptly 4. Use an oral moisturizer to relieve dry mouth

A distraught parent informs the nurse of bleeding in a 1-day-old girl. What is an appropriate response by the nurse after finding a small amount of bloody mucus in the newborn's diaper? 1. "Laboratory work will need to be completed to determine your newborn's hormone levels." 2. "The health care provider will prescribe a dose of medication to stop the bleeding." 3. "We will continue to monitor the amount, color, and consistency of the drainage." 4. "What visitors have been present since the baby was born?"

A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools

A nurse receives report on a group of clients. Which client should the nurse assess first? 1. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions 2. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak 3. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air 4. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear

An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which data obtained by the practical nurse is most important to report to the registered nurse before the client receives the next dose? 1. Blood pressure of 104/62 mm Hg 2. Blood urea nitrogen of 20 mg/dL (7.1 mmol/L) 3. Client report of tinnitus 4. Urine output of 400 mL since last dose

Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom? 1. A temperature of 99 F (37.2 C) that occurs during the evening 2. The child cannot recall items eaten for lunch the previous day 3. The child vomits after awakening from a nap and again 1 hour later 4. The VP shunt is palpated along the posterolateral portion of the skull

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? 1. Check for a history of bipolar disease 2. Determine if restraints can now be removed 3. Monitor for ECG changes 4. Obtain blood for the current blood alcohol level

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? 1. "I've felt the need for an afternoon nap most days this week." 2. "I've gained 3 lb (1.36 kg) since I began taking this medication." 3. "I've had the stomach flu for the past couple of days." 4. "My mouth seems to be drier than usual lately."

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? 1. 1-month-old infant born at term gestation who exclusively breastfeeds 2. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula 3. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk 4. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning? 1. "Because apples are healthy, we make apple pie and feed small, soft bites to our baby." 2. "If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted." 3. "Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast." 4. "We found that the food in TV dinners can be easily pureed and is convenient."

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1. Blood urea nitrogen of 12 mg/dL (4.28 mmol/L) (5%) 2. BMI of 34 kg/m2 recorded during today's examination (3%) 3. Past medical history of uncontrolled hypertension (59%) 4. Takes alprazolam as prescribed for anxiety (32%) IncorrectCorrect answer 3 59%Answered correctly 24 secsTime Spent 10/24/2020Last Updated

The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." 2. "I should give this medication with or just before my child has a meal or snack." 3. "It is okay for my child to chew this medication." 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? 1. Client has 1 emesis of green fluid 2. Client has had no bowel movement for 2 days 3. Client falls asleep while talking to the nurse 4. Client reports experiencing pruritus

The nurse has reinforced education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Eliminating aged cheeses and processed meats from my diet is essential." 2. "I can skip doses on days that I am not feeling anxious." 3. "I will take my daily dose at bedtime." 4. "Using sunscreen is important as this drug will make me sensitive to sunlight."

The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity? 1. Encouraging use of puzzles for play 2. Offering the child stacking blocks for diversion 3. Providing crayons to draw noses on facemasks 4. Suggesting that playmates visit the child

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The nurse knows that this therapy is given to: 1. Fight the infection 2. Minimize rash 3. Prevent heart disease 4. Reduce spleen size

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider? 1. "I don't have much interest in sex lately." 2. "I feel like I might be getting a cold." 3. "My periods have been heavy lately." 4. "These hot flashes are occurring a lot."

The nurse is caring for an infant with osteogenesis imperfecta admitted with a new fracture. The client also has old fractures in multiple stages of healing but no bruising, abrasions, or redness of the skin. Which nursing intervention should be included in the plan of care? 1. During diaper changes, carefully lift the infant by the ankles 2. Lift from under the arms when picking up the infant 3. Obtain blood pressure manually to avoid cuff over-tightening 4. Request a social work consultation to assess for child abuse

The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse? 1. Female client with a fractured pelvis who is 4 months pregnant 2. Female client with cytomegalovirus pneumonia 3. Male client with an open bowel resection with a Foley catheter 4. Male client with history of Billroth II surgery who is septic

The nurse is preparing to administer IV cefazolin to a client who is newly admitted with cellulitis. The client's allergies include amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first? 1. Administer the medication as ordered 2. Clarify the order with the supervising registered nurse 3. Get more information from the client about the client's allergies 4. Notify the pharmacy that the drug is inappropriate for this client

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? 1. "A contrast medium is administered rectally to visualize the colon via x-ray." 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." 3. "This enema assists the large intestines in removing excess potassium from the body." 4. "This enema is administered before bowel surgery to decrease bacteria in the colon."

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? 1. Administering PRN antiemetic prior to the infusion 2. Administering via an infusion pump over at least 30 minutes 3. Drawing a trough level just prior to administration of the vancomycin 4. Starting a new IV line before administration

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? 1. "I need to continue to avoid eating spinach and kale." 2. "I probably will have some weakness in my legs when I take this medicine." 3. "I should avoid taking aspirin while receiving this medication." 4. "I will have to get blood drawn routinely to check my clotting levels."

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss? 1. Heart valve injury 2. Intellectual disability 3. Joint destruction 4. Recurrent pneumonia

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorvastatin for hyperlipidemia in a client with angina pectoris 2. Bupropion for smoking cessation in a client with emphysema 3. Cyclobenzaprine for muscle spasms in a client with hepatitis 4. Metronidazole for trichomoniasis in a client with Crohn disease

The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic? 1. Call the office if the toddler's temperature is higher than 100 F (37.7 C) 2. Fussiness and anorexia are common for 1 week after immunizations 3. Redness at the injection sites and a mild fever are common 4. The toddler's activity level should be restricted for 24 hours

The nurse obtains a health history from a client who states, "I skip dinner most nights to lose weight. I don't want to get low blood sugar, so I don't take my evening dose of metformin when I skip dinner." Which response by the nurse is appropriate? 1. "Have your blood sugars been in the desired range when you skip doses?" 2. "Take half of the evening dose to prevent a low blood sugar level." 3. "The risk of low blood sugar is minimal when metformin is taken without food." 4. "Why are you skipping meals? That is not a healthy weight loss strategy."

The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects? 1. Decreased blood pressure and growth delays 2. Heart palpitations and weight gain 3. Loss of appetite and restlessness 4. Trouble sleeping and a dry cough

The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective? 1. "An additive-free, low-sugar diet will reduce my child's symptoms." 2. "I can now manage my child's condition on my own." 3. "My child should take the last daily dose of methylphenidate before 6:00 PM." 4. "Once the medication is started, I will not have to monitor my child anymore."

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? 1. "I should not donate blood while taking this medication." 2. "I will stop taking my tetracycline prior to taking this medication." 3. "I will take vitamin A supplements." 4. "I will use condoms and birth control pills."

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? 1. "I will call my health care provider if I notice red urine or blood in my stool." 2. "I will not stop taking dabigatran even if I get a stomachache." 3. "I will place capsules in my pill box so I will not forget to take a dose." 4. "I will swallow the capsule whole with a full glass of water."

The nurse reinforces teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? 1. "I should get a flu shot this year as my resistance to germs will be lower." 2. "I should not get pregnant while taking this medicine." 3. "I will make sure I have my eyes checked every 6 months." 4. "It will be difficult, but I will not have wine with my dinner."

The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Driving is not recommended until I stop taking this medication." 2. "If I experience a panic attack I should take an extra dose of medication." 3. "It will be 2-4 weeks before I feel the full effect of this medication." 4. "Withdrawal symptoms will occur if I abruptly stop taking this medication."

The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious, adverse effect of the medication? 1. Diarrhea 2. Headache 3. Muscle aches 4. Numbness in the feet

The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include? 1. Notify the health care provider if your urine is red 2. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication 3. Wear eyeglasses instead of soft contact lenses while taking this medication 4. You can stop taking the medications as soon as one sputum culture comes back normal

The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin? 1. Blood in nasogastric tube drainage 2. Decrease in red blood cell count 3. Increase in serum creatinine level 4. Onset of muscle aches and cramping

The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 7-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern? 1. "I get embarrassed if my child screams when approached by unfamiliar people." 2. "I thought my child would be sitting without needing their hands for support by now." 3. "I wonder when my child will put their pacifier to their mouth without my help." 4. "It seems odd that my child says 'mama' and 'dada' to strangers."

The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments? 1. Attention span and activity level 2. Dental health and mouth dryness 3. Height/weight and blood pressure 4. Progress with schoolwork and in making friends

The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation? 1. Bilateral bowlegs (genu varum) in a 15-month-old 2. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant 3. Lateral curvature to the spine noted on examination of a 10-year-old girl 4. Presence of an S3 heart sound in a 2-year-old

The practical nurse is collecting data on 4 infants in the pediatric unit. Which assessment finding would the practical nurse report to the registered nurse? 1. 3-week-old whose anterior fontanelle bulges slightly with crying 2. 4-week-old whose posterior fontanelle is flat and soft 3. 6-month-old with birth weight of 7 lb 3 oz (3.3 kg) who now weighs 12 lb (5.4 kg) 4. 12-month-old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg)

The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse? 1. Hair loss 2. Nausea 3. Petechiae 4. Stomatitis

The practical nurse monitoring a 3-year-old finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the practical nurse anticipate? 1. 20-gauge needle insertion at the mid-axillary line for pleural aspiration 2. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure ventilation standing by 3. Intubation in the operating room with a prepared tracheotomy kit standing by 4. Nebulized racemic epinephrine with a pediatric anesthesiologist standing by

The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed-head injury who is 1 day post craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client's medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification? Click on the exhibit button for additional information. 1. Acetaminophen 1,000 mg IV, every 6 hours 2. Gabapentin 300 mg orally, every 8 hours 3. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours prn 4. Phenytoin 100 mg orally, every 12 hours

The women's health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse? 1. Client reports heavy menstrual cycles 2. History of breast cancer in maternal aunt 3. History of deep venous thrombosis 4. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m2

Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply. 1. After albuterol administration, 5-year-old client has a pulse of 120/min and reports tremor 2. After hydromorphone 1 mg IV push, blood pressure decreases from 130/80 mm Hg to 110/70 mm Hg 3. Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine 4. Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion; current values are 90/70 mm Hg and 100/min, respectively 5. Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction

3,4,5

A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed? Select all that apply. 1. Haemophilus influenzae type b (Hib) 2. Hepatitis B (Hep B) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate (PCV) 5. Varicella

3,5

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? 1. "I am not sleeping well at night and would like a sleeping aid." 2. "I do not know how well I will do on this restricted diet." 3. "I have been having quite a bit of nausea and constipation." 4. "This medicine is not working; I am so tired of being depressed."

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. 1. Atorvastatin 2. Metformin 3. Metoprolol 4. Olanzapine 5. Omeprazole

3,4

The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.

3,4

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.

3,4,5

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which findings does the nurse expect to observe? Select all that apply. 1. Absent deep tendon reflexes 2. Cold, clammy skin 3. Muscle rigidity 4. Restlessness and agitation 5. Sinus tachycardia

3,4,5

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1. "A high-calorie, high-protein diet is best for our child." 2. "It is extremely important that we do not allow our child to become dehydrated." 3. "Our child should wear a medical alert bracelet at all times." 4. "We should avoid giving our child over-the-counter medicine containing aspirin." 5. "We should encourage a noncontact sport such as swimming."

3,4,5

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply. 1. Dodgeball 2. Reading a book 3. Stationary bicycling 4. Swimming 5. Yoga

3,4,5

The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply. 1. Administering oral pain medication if client reports low back pain 2. Checking for bleeding at the catheter insertion site every 15 minutes 3. Performing post-procedure vital sign measurements 4. Reinforcing instructions to keep the involved extremity straight 5. Reviewing ECG for dysrhythmias

3,5

The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent gastric irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption."

3,5

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? 1. Atrial fibrillation is converted to sinus rhythm 2. Blood pressure is 126/78 mm Hg 3. No signs or symptoms of stroke 4. Ventricular rate decreased from 158/min to 88/min

A 9-year-old has terminal cancer, but the parents do not want the child to know the prognosis. The child has been asking questions such as what dying is like and whether the child will die. Which action by the nurse is most appropriate? 1. Encourage the child to ask the parents these questions 2. Notify the supervising registered nurse about the child's questions 3. Reassure the child that everyone is trying to help the child get better 4. Tell the parents about the child's questions

The nurse is reinforcing teaching about breastfeeding to a postpartum client. Which statement by the client indicates a correct teaching?

3. "If I need to reposition my baby's latch, I will use my finger to break the suction first."

A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32k. Which teachings should the nurse reinforce as part of proper preconception health care for this client?

A,D,E

A 9-year-old with type 1 diabetes takes insulin glargine and NPH regularly. While at school, the client becomes shaky, diaphoretic, and pale. What is the most appropriate action by the nurse? 1. Administer scheduled dose of NPH insulin 2. Give emergency glucagon IM injection 3. Give peanut butter and crackers 4. Provide 4 oz (120 mL) of a regular soft drink

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse anticipate in this client's care plan? 1. Encourage client to drink cold beverages 2. Encourage client to eat a high-fiber diet 3. Encourage client to perform facial massage 4. Encourage client to report any fever or sore throat

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

3. Resume chest compressions at a rate of 100/min

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset severe, right lower abdominal pain and dizziness. Which additional assessment finidngs will the nurse anticipate if the client is experiencing ruptured ectopic pregnancy?

A,D,E

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to reinforce to the client? 1. Report for periodic laboratory tests for kidney, liver, and blood functions 2. Store the medication in a cool, dry place away from direct heat and light 3. Take the medication after a meal to prevent gastric distress 4. Take the medication with a full glass of water and increase fluids during the day

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse? 1. Diffuse muscle pain 2. Flushing and pruritus 3. Low blood pressure 4. Wheezing and hives

A client without prenatal care gives to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse?

A,D,E

The nurse is discussing child safety with the parents of a 12-month-old who is just beginning to walk. Which statement by the parents indicates a need for further instruction? 1. "Our swimming pool is fenced in with a lock on the gate." 2. "We have installed childproof gates at the top and bottom of our stairs." 3. "We need to lower the mattress in our child's crib." 4. "When we can't be watching, we put our child in a mobile child walker."

A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m2 (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine? 1. Child's pattern of daily physical activity 2. Family's eating habits 3. Family's financial resources for purchasing healthy foods 4. Family's readiness for change

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond? 1. Determine if the client wore protection 2. Inform that parental consent is required 3. Inform that the request is honored if the client has symptoms 4. Provide requested service

The charge nurse in a long term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel?

A,D,E

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation.

A,D,E

A client has been admitted to the acute impatient psychiatric unit with a diagnosis of major depressive disorder. The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which the 2 key clinical findings daily for at least 2 weeks?

3. Depressed mood or loss of interest or pleasure

The practical nurse collaborates with the registered nurse to develop a care plan for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome is the priority?

3. Increased caloric intake to gain weight

Unlicensed Assistive Personnel (UAP) report 4 situations to the nurse. Which situation warrants nurse intervention first?

3. Puncture-resistant sharps disposal container on the is full.

Which statements related to ethical nursing practices are correct?

A,D,E

A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child's parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse? 1. The parent cannot stay at the hospital due to potential job loss if late for work 2. The parent does not seem to be concerned about the child's condition 3. The parent is single 4. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old

Which situations would require the nurse to obstain a prescription for physical restraints? Select all that apply

A,E

A client recently diagnosed with heart failure is being discharged on the angiotensin-converting enzyme inhibitor lisinopril. Which information related to this new medication is important for the nurse to reinforce at discharge? 1. Instruct client to report for monthly blood work to monitor drug levels 2. Review foods high in potassium that client should include in diet 3. Teach client to check own pulse for 1 minute; hold medication if heart rate is <60/min 4. Teach client to rise slowly and sit on side of bed for several minutes before rising

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? 1. Ask if the client needs to use the bedpan 2. Assess the client's fluid intake 3. Assess the client's skin turgor 4. Palpate the client's suprapubic area

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information. 1. Calcium 7.4 mg/dL (1.85 mmol/L) 2. Creatinine 4.0 mg/dL (353 µmol/L) 3. Phosphorus 3.9 mg/dL (1.26 mmol/L) 4. Potassium 4.9 mEq/L (4.9 mmol/L)

A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client? 1. "A diet rich in protein and vitamin D will help with absorption." 2. "If the tablet is too large to swallow, crush and take it in applesauce or pudding." 3. "Potassium tablets should be taken on an empty stomach." 4. "Take it with plenty of water and sit upright for a period of time afterward."

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse is reinforcing discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? 1. "I can continue to take my prescription of sildenafil." 2. "I should take the patch off when I shower." 3. "I will remove the patch if I develop a headache." 4. "I will rotate the site where I apply the patch."

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. 1. Bruising easily, especially on the arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in the legs

A newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding? 1. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2 2. Small amount of non-formed stool in the colostomy bag on postoperative day 6 3. Stoma bleeds a small amount during colostomy bag change on postoperative day 3 4. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5

A nurse has reinforced teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? 1. "I need to drink 1-2 liters of fluid daily." 2. "I need to have my blood levels checked periodically." 3. "I should not limit my sodium intake." 4. "I should use ibuprofen for pain relief."

A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs? 1. Appearance of upper lip hair 2. Increase in height 3. Presence of axillary hair 4. Testicular enlargement

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in a relative's home and the nurse is questioning the safety of the home, knowing it may be necessary to arrange for an alternate living situation or additional support. To address this concern, it is most appropriate for the nurse to consult with which interdisciplinary team member? 1. Adult protective services 2. Physical therapist 3. Physician 4. Social worker

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client? 1. Avoid a high-potassium diet 2. Exercise regularly and maintain a high-fiber diet 3. Maintain oral hygiene 4. Report excessive urination and increased thirst

A practical nurse in the cardiac intermediate care unit is assisting the registered nurse caring for a client with acute decompensated heart failure. The client also has a history of coronary artery disease and peripheral vascular disease. The practical nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information. 1. Aspirin 2. Atorvastatin 3. Furosemide 4. Metoprolol

After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first? 1. Administer diphenhydramine 2. Administer injectable epinephrine 3. Examine the client's trunk and limbs 4. Reassess the client's allergy history

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel a little dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal."

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? 1. Apical heart rate is 62/min 2. Blood sugar level is 240 mg/dL (13.3 mmol/L) 3. Client is taking 20 mg fluoxetine daily 4. Serum creatinine is 2.3 mg/dL (203 µmol/L)

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min

NCLEX-PN TEST - Kehinde The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler? 1. ½ cup orange juice 2. Dry, sweetened cereal 3. Raw carrot sticks 4. Slice of cheese

NCLEX-PN TEST - Kehinde Balogun 00:06:23 41 of 85 0 A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce? 1. Apply lubricating eye drops when wearing contacts 2. Do not break, crush, or chew capsules 3. Use sunscreen routinely during therapy 4. Use two forms of contraception consistently

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? 1. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern." 2. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible." 3. "Newer research shows that thumb sucking has little effect on a child's teeth." 4. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth."

The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed? 1. "I will need to get my blood drawn to see if I'm taking the right dose." 2. "I will probably need to take this the rest of my life." 3. "I will take this once a day in the morning." 4. "If this makes my stomach upset, I will take it with an antacid."

The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? 1. "Treatment will be considered a success when my child grows at a rate equal to peers." 2. "Treatment will be required throughout my child's life." 3. "Treatment will begin when my child becomes an adolescent." 4. "Treatment will require a daily injection under my child's skin."

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? 1. C-reactive protein (CRP) 2. Prothrombin time (PT) 3. Serum LDL cholesterol 4. Tuberculin skin test (TST)

The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse reinforces which teaching regarding correct timing of medication administration? 1. At noon with a meal 2. In the morning on an empty stomach 3. In the morning with breakfast 4. With the evening meal

The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin? 1. "I will call the health care provider if I don't feel like eating." 2. "I will call the health care provider if I feel dizzy and lightheaded." 3. "I will call the health care provider if I have trouble reading." 4. "I will take my blood pressure before taking my medicine."

The nurse assists with a community teaching program for parents and caregivers of infants. Which statement by a participant indicates that teaching has been successful? 1. "After age 6 months, it is safe to use honey to sweeten my infant's formula." 2. "I should wait until my infant is 1 year old to introduce egg products." 3. "I will switch my 1-year-old to low-fat milk instead of commercial formula." 4. "My infant should be able to pick up small finger foods by age 10 months."

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. "A power of attorney (POA) is good to have in place. It sounds like you are on the right track." 2. "Great. Your POA can start to make decisions for you when you are no longer able to do so." 3. "Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order." 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you."

The nurse in a clinic is caring for an 8-month-old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent? 1. Administering a cough suppressant and antihistamine 2. Prophylactic treatment of family members 3. Temporary cessation of breastfeeding 4. Use of saline drops and a bulb syringe to suction nares

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear 2. 4-year-old post adenotonsillectomy who is now reporting ear pain 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow

The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? 1. The parent cannot stay at the hospital due to potential job loss from absence 2. The parent is in the process of a divorce and will soon be a single parent 3. The parent is witnessed stealing food and drinks from the cafeteria 4. The parent leaves the client's younger sibling to care for the client's newborn sibling

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction? 1. "I should avoid alcohol intake with this new medication." 2. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." 3. "I should read the labels on all foods I eat, including those that say 'sugarless'." 4. "This medication will help me lose weight."

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider? 1. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L) 2. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L) 3. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L) 4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

The nurse is providing care to a 1-year-old recently diagnosed with failure to thrive. Which intervention is the priority nursing action for this child? 1. Assess overall parenting skills 2. Have the parent complete a 24-hour dietary intake 3. Measure the child's height, weight, and head circumference 4. Observe the child feeding

The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? 1. "We will encourage extra fluid intake while our child is sick." 2. "We will increase the frequency of blood glucose checks." 3. "We will monitor our child's urine for ketones with each void." 4. "We will not administer insulin if our child is unable to eat."

The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching? 1. "I will offer my child options rather than asking yes or no questions." 2. "I will wait at least 15 minutes after a play period to offer a meal to my child." 3. "If my child is having a tantrum, I will have them sit in a quiet area for a short time-out." 4. "If my child refuses a meal, I will have them stay at the table until they eat half the food."

The nurse is reinforcing instructions related to antibiotic eye drop administration to the parent of a 5-year-old with bacterial conjunctivitis. Which instruction is most important? 1. Discard tissues used to blot excess medication from the eye immediately 2. Have your child lie down before you instill the eye drops 3. Use warm, moist compresses to remove crusting on eyelids 4. Wash hands before and after eye drop instillation

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider? 1. "I am tired of restricting my fluids but know I need to." (9%) 2. "I feel like I am beginning to get sick with a bad cold." (9%) 3. "I have been getting a lot of nasal pain with this spray." (22%) 4. "I have recently started to experience frequent headaches."

The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction? 1. "I can take this medication with food if it hurts my stomach." 2. "I must use a reliable form of birth control while taking this medication." 3. "I should continue to take my ibuprofen as prescribed." 4. "I will take this medicine with an antacid to decrease stomach upset."

The nurse reviews new laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the supervising registered nurse? 1. CD4+ cell count of 500/mm3 in a client with HIV and oral candidiasis who is receiving PO fluconazole 2. Hemoglobin A1c of 7.3% in a client with type 2 diabetes and pneumonia who is receiving IV levofloxacin 3. Platelet count of 152,000/mm3 in a client with a venous thrombosis who is receiving a continuous heparin infusion 4. Serum glucose of 65 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition

The parent of a 15-month-old calls the nurse and says that the child developed a rash and mild fever after receiving a routine measles, mumps, rubella, and varicella (MMRV) vaccine in the pediatric clinic 5 days ago. What is the best response by the nurse? 1. "Apply over-the-counter hydrocortisone cream to the rash." 2. "Bring your child to the clinic this afternoon." 3. "This is a common reaction to the MMRV vaccine." 4. "What is your child's temperature right now?"

The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse? 1. "Methylphenidate is generally a safe and effective drug for children with ADHD." 2. "Methylphenidate will increase the levels of neurotransmitters in your child's brain." 3. "You should see your child's school grades improve." 4. "Your child should be able to more easily complete school assignments and other tasks."

The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what? 1. React anxiously to altered daily routines 2. Realize that death eventually affects everyone 3. Think about the religious or spiritual aspects of death 4. Understand that death is permanent but be curious about it

Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first? 1. Have unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the supervising registered nurse 3. Obtain the client's prn labetalol from the medication dispensing machine 4. Recheck the client's blood pressure with a manual cuff

What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting 2. Playing a game of Chinese checkers in the activity room 3. Playing video games 4. Watching a favorite movie

A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. 1. Blood pressure of 140/84 mm Hg 2. Heart rate of 98/min 3. Platelet count of 200,000/mm3 (200 x 109/L) 4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease

4,5

The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply. 1. Avoid driving while taking this medicine 2. Change positions slowly 3. Discontinue immediately if suicidal thoughts occur 4. Notify the health care provider of tarry stools 5. Take the medicine with food

4,5

The nurse is reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply. 1. Calcium 2. Fiber 3. Iron 4. Vitamin D 5. Vitamin K

4,5

Which prescriptions for these clients does the nurse question? Select all that apply. 1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

4,5

The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate? 1. "I need you to take vital signs on all clients in rooms 1 through 10 this morning." 2. "Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely." 3. "Please ensure that Mr. Garcia in room 8 ambulates several times." 4. "Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100."

Asymmetrical chest expansion and decreased breath sounds on the left

A client who fell and hit the head but refuses to go to the emergency department a client who needs prefilled insulin syringes a client with stage III pressure injury in need of the dressing change

The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?

A. Assist client, post hip fracture repair, to the bathroom

The nurse is working with unlicensed assistive personnel (UAP). Which task can the nurse safely assign to UAP?

A. Assisting a 2-day postoperative hip arthroplasty client with morning care

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply.

A,B,C

A client with ST segment elevation myocardial infartion is due for 9:00 am medications. Based on the data shown in the exhibit, which medications should the nurse administer.

A,B,C

The nurse is performing post delivery care of a newborn delivered at 35 weeks gestation. Which of the following actions by the nurse are appropriate?

A,B,C

The nurse reinforces safety precautions of home oxygen use to a client with COPD being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching?

A,B,C

A client with bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep?

A,B,C,D

The medical surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the hcp during the middle of the night? Select all that apply.

A,B,C,D

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply.

A,B,C,D

The nurse is reviewing a client health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply??

A,B,C,E

A nurse is caring for a client who had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a know risk factor for suicide in this client?

A,B,C,F

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy, the last infusion was about a week

A,B,D

Go to the coin thing controlled breathing exercises

47-year-old client with polycystic ovary syndrome obesity and a history of unsuccessful in fertility treatments

The night nurse reports that the hospitalized with major depressive disorder has been unable to go to sleep until late at night. The client gets up, paces the hallway, wrings the hands, and appears teary, Which interventions does the nurse advocate adding to the care plan?

A-Arrange for the client to receive 20 minutes of natural sunlight each day. D. Serve the client with a glass of warm milk in the evening. E.Spend time with the client in a quiet environment just before bedtime. F. Tell the client to take a warm bath before bed.

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 1. Ask the interpreter to explain the discussion 2. Confirm the client's consent with the interpreter, using gestures 3. Have the interpreter witness the signature 4. Indicate that the interpreter was used when witnessing the client's signature

The nurse recognizes that it is acceptable for which pair of clients to be assigned to share a semi-private room.

A. 35 yr old with blood loss anemia and a 40 yr old diagnosed with pneumonia

A category 4 hurricane has disrupted a rural, local health care system, creating a significant increase in emergency department admissions. Which client would the nurse anticipate as the priority for intervention?

A. 7-year-old with status asthmaticus and an oxygen saturation of 89%

The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?

A. A 2-month-old who rolled off the changing table and is now lethargic

A school observes a 3 yr old begin to choke and turn blue while eating lunch. What should be the nurses initial intervention?

A. Abdominal thrusts

A nursing diagnosis of ineffective airway clearance related to pain is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

A. Administer prescribed analgesic medication for incision pain

The client with malignant left pleural effusion undergoes a thoracentesis and 900 ml of excess pleural fluid is removed. Which of these manifestations, if noted on the post procedure assesment, should the nurse report to the health care provider immediately?

A. Asymmetrical chest expansion and decreased sounds on the left

The nurse is assesing a clients peripheral pulses. The nurse palpates the top portion of the clients foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. Hoe should the nurse document these findings?

A. Bilateral dorsalis pedis pulses palpable. Right DP 2+,left DP 1+

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction?

A. Bishop score of 10

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-min commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder.

A. Agoraphobia

A nurse is caring for a postpartum client who has breast engorgement following breastfeeding. Which instructions should the nurse reinforce regarding relief of breast engorgement?

A. Allow newborn to nurse for at least 10-15 minutes on each breast.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the clients back pain during early labor?

A. Applying counterpressure to the clients sacrum during contractions

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?

A. Ask the spouse to further describe the client symptoms

The 11:00 am routine fingerstick test for a client was assigned to the uap by the nurse. At 11;15 the client tells the nurse that no one checked the blood level. The nurse should take what action first.

A. Ask the uap about the situation

A client with borderline personality disorder says to the nurse, You're the only one I trust around here. The others dont know what they are doing, and they dont care about anyone except themselves. I only want to talk with you. What priority action should the nurse advocate to be included in the clients nursing care plan?

A. Assign different staff members to care for the client each day

The telemetry nurse is reviewing a clients cardiac rhythm strip. What is the correct interpretation for this strip.

A. Atrial paced rhythm

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?

A. Avoid strenous actiity before this surgery.

The home health nurse is providing care for a 6 yr old client who has a tracheostomy and is being mechanically ventilated when the ventilator apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present. Which action should the nurse take first?

A. Begin chest compressions

The nurse supervisor tells the practical nurse to go to the telemetry unit as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the PN

A. Clarify the skills/knowledge that the nurse is able unable to perform

The nurse has received report on the following clients. Which client should be seen first?

A. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg

A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client.

A. Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

A. Client who had a foot amputation today reporting left shoulder pain radiating down the arm.

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?

A. Client who has a carotid endarterectomy that day with a blood pressure of 160/88

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume 80ml. Which action should the nurse perform next.

A. Collect gastric pH measurement

The nurse observes a nursing student performing chest compressions on an adult client. What technique indicates the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation?

A. Compressing the chest to a depth of at least 2 in 5 cm

The nurse is monitoring a client who is in active labor with a cervical dilation of 6cm. Which uterine assessment finding requires an intervention by the nurse.

A. Contraction duration of 95 seconds

The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the clients behavior?

A. During 1-2 hours after each meal

The practical nurse is assisting the registered nurse to care for a 6 hour old term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborns blood glucose level is 45. The newborn is asymptomatic. Which intervention should the PN anticipate implementing first?

A. Feed the newborn

The nurse is reinforcing information to a client in preparation for discharge from the hospital when the client breaks down crying saying the health care provider thinks I am crazy because I was diagnosed with a functional disorder. Which statement would be the best reply to this client?

A. Functional disorder is a diagnosis for a genuine medical issue that medical science does not fully understand

The women health nurse is evaluating preconception teaching for a client with tyoe 2 diabetes mellitus controlled with insulin. Which statement by the client demonstrates an appropriate understanding of teaching?

A. Having my hemoglobin a1c under control before pregnancy lowers my babies risk of defects.

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assesment, the nurse should anticipate that the health care provider will order which laboratory test?

A. Hemoglobin and hematocrit levels

A client with coarse crackles at the base of both lungs becomes suddenly agitated anxious, cyanotic, and dyspneic. Which of the following positions is appropriate.

A. High Fowlers

A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?

A. I have signed up to be a dog walker when I normally would watch television?

A client who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 min. The client says, I'm not hungry and I don't like doing anything. What is the best response by the nurse?

A. I will help you get ready then we can walk to the dining room together.

The lpn assigns the ambulation of a client to uap. The lpn observes uap placing the clients foley bag on the iv pole at the level of the clients chest during client ambulation down the length of the hallway. What action should the LPN take initially?

A. Immediately lower the bag and speak privately to uap

A client with moderate Alzheimer disease is started in memantine. What should the nurse monitor to evaluate the effectiveness of this medication?

A. Improved ability to perform activities of daily living.

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage.

A. Infant birth weight of 9 lb 2 oz

The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the highest priority to report the registered nurse?

A. Pain and pallor in one foot

The nurse is reinforcing education to a pregnant client who is HIV positive. Which information is appropriate for the nurse to include??

A. Prescribed antiretroviral therapy should be continues during pregnancy.

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action is next?

A. leave the catheter in place and insert a new catheter higher up in the perineal area

The nurse is caring for 4 clients. Which client should the nurse see first?

A.2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs

The nurse is caring for the assigned clients on a pediatric impatient unit which client is the priority

Eight-year-old with sickle cell crisis who had a sudden onset and unilateral arm weakness

Exposing us on my world wars in my psoriasis

Administer prescribe me and I'll just take medication for incisional pain

The intensive care unit is caring for a client who has just been asked to be end it which interventions are appropriate at this time select all that apply

Administer warm to humidified oxygen VI a face mask provide mouth Kerr with oral sponges and start the client on incentive spirometer

A client comes to the emergency department for the second time with shortness of breath and sub sternal pressure that radiates to the jar the notes understands that and Gina victorious may precipitated by which of these factors select all that apply

Amphetamine useCigarette smoking called exposure sexual intercourse

A 60-yr old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench 100 miles from home. The client is brought to the emergency department by the police. The client can state mane and address but has no recollection of the past 2 days. What is the priority nursing action?

Assess vital signs

Are you 60-year-old client wanders away during halftime at a football game and his farm 48 hours later sleeping on a park bench 100 miles from home the client is rods in the emergency department by police the client can state name and address but has no recollection of the past two days when is the priority Nursing action

Assessed vital signs

The nurse is inspecting the legs of a client with a suspected lower extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect?

B,D,E

I can use a salt substitute because I'm required to restring both sodium and potassium with my daily diet

Asymmetrical chest expansion and decreased breath sounds on the left

The nurse is reinforcing teaching of a proper technique for a colostomy irrigation for the home, health client which client action in the case of further instruction is required

Attaches in an email sent to the irrigation bag lubricated gently and service it to the stoma and hold it in place

A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?

Auscultate breath sounds

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?

B Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours

The nurse is reinforcing teaching to an overweight 54 yr old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply

B and C

A client at 34 weeks gestation has constipation. The client has been takign 325 mg anemia since the last appointment 4 weeks ago. Which instructions should the nurse reinforce for this client?

B,C

The emergency department nurse cares for a client whose college roommate reports recent changes in the clients behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit?

B,C

The nurse on the mental health unit is collaborating with the registered nurse to develop the care plan for a newly admitted client with a diagnosis of schizophrenia with persecutory delusions. Which interventions should the nurse expect to include with regard to the delusional thinking? Select all that apply.

B,C

A practical nurse is collaborating with the RN to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care?

B,C,D

The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurence?

B,C,D

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate?

B,C,D,E

The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client? Select all that apply.

B,C,D,E

An adolescent client is brought to the emergency department by the parents after being found making superficial cuts along the side of an arm with a razor blade. There are minor cuts in various stages

B,C,E

An infant is born with cleft palate. Which actions will promote oral intake until the defect can be repaired. Select all that apply.

B,C,E

The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed?

B,C,E

The practical nurse is caring for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data?

B,C,E

The practical nurse is collaborating with the registered nurse to develop a plan of care for a 16-yr client with bulimia nervosa. Which interventions would be included in the plan of care?

B,C,E

Which actions would the nurse expect to be included in the care plan for client hospitalized for bipolar disorder, acute manic episode?

B,C,E

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.

B,D,E

The practical nurse is collecting data on several clients in the antepartum unit. Which client should the practical nurse report to the registered nurse for further assesment?

B. 25 weeks gestation, hemoglobin is 9

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?

B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy

The pediatric nurse receives report on 4 clients. Which client should the nurse see first?

B. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside

The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of non-immune. What will the nurse anticipate as the plan of care for this client?

B. Administer MMR vaccine immediately postpartum

The school nurse is called to the classroom to assist with attention deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take?

B. Ask the child to blow up a balloon

During the charges morning rounds, a client says I hope you will take better care of me than the nurse I had last night. What should be the charges nurses initial response?

B. Ask the client to describe what happened last night.

During the nurses morning rounds a client says I hope you will take better care of me than the nurse I had last night. What should be the charge nurses initial action?

B. Ask the client to describe what happened last night.

The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate intervention?

B. Ask the client to wait until the hcp prescriptions can be verified.

The practical nurse is assisting the registered nurse during admission of a client with heart failure related fluid overload. Which action should be completed first?

B. Assess the clients breath sounds

A pregnant client comes to the labor and delivery unit stating, "my water jusst broke at home," On assessment of the client's perineal area, the nurse visualizes a loop of umbillical cord protruding from the bagina. Which nursing intervention would be appropriate?

B. Assist the client to the knee chest position

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as most appropriate to promote client nutrition?

B. Cheeseburger apple, vanilla milkshake

The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first?

B. Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia and delirium. The nurse identifies which assessment finding as most consistent with the diagnosis of delirium?

B. Client is inattentive and hallucinating.

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention?

B. Client is taking lisinopril to control hypertension

The nurse has just received report on 4 clients. Which reported information is the most concerning?

B. Client reporting back pain 1 hour following coronary angiography.

A 12-yr old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child?

B. Connect the dots puzzle book

The nurse is observing a pregnant client receiving an oxytocin infusion for induction of labor. The baseline fetal heart rate is 140/min the strip is shown in the exhibit. What is the nurses best course of action?

B. Continue to monitor the client

A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new onset confusion by assessing the clients sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?

B. Delirium

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family and immediately begins to verbally abuse a roommate?

B. Displacement

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse?

B. Distant heart tones and jugular venous distension

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21. A genetic screen and an echocardiogram are scheduled that day. The neonates vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?

B. Document the finding

The nurse is assigned to care for four clients. Which client should the nurse see first?

B. Female client who had an open reduction and internal fixation of tibia and reports severe pain and pressure under the cast and in the toes ability to move

AA client with (OCD) has been cleaning a bathroom for most of the morning. When the roommate demand that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, You cant make me leave, everything is still dirty. What is the best nursing action?

B. Give a reminder that the client has been cleaning the bathroom for 1 1/2 hours and it is time to take a break.

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior the client says With my spouse dead theirs no reason for me to go on. What is the best nursing response?

B. Have you thought of hurting yourself

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?

B. I will let my daughter fix my hair until my health provider says I can do it.

The nurse is reinforcing teaching to a support group for partners of military veterans suffering from posttraumatic stress disorder. A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms?

B. Increased anxiety, reliving the event, feeling detached from others.

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in the client learns of gaining 2 lb. and says to the nurse, "See what you force feeding has done to me? I'm fatter and uglier than ever" What is the nurses best action

B. Initiate one-on-one supervision of the client during feedings.

The clinic nurse is reinforcing instructions to a client who will be wearing a holter monitor for the next 24 hrs. Which instructions are important to review with the client?

B. Keep a diary of activities and any symptoms experienced

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate?

B. Let's step away from the crowd to discuss it."

A client with a 20 yr history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I cant find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?

B. Lets go back to your room and look for your headband together.

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors

B. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration

A client with schizophrenia says to the nurse The world turns on a ball at the beach. But all the worlds a stagecoach and I took the bus home. The nurse recognizes this statements as an example of which of the following?

B. Loose associations

The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel?

B. Lower the temperature in the room to make the environment cooler

The nurse is monitoring a newborn with skin discoloration in the lumbar area. Which action by the nurse is appropriate?

B. Measure and document the size and location of the markings

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusions needs to be turned off?

B. Partial Thromboplastin

A client is admitted to the postpartum floor after a vaginal birth. Which findings indicate the need for immediate intervention?

B. Persistent headache with blurred vision

A 2 yr old at an outpatient clinic stops breathing and doesnt have a pulse. CPR is initiated. When the automated external defibrillator arrives, the nurse notes that it has only AED pads. What is the appropriate action at this time?

B. Place one AED on the chest and the other on the back.

NCLEX-PN TEST - Kehinde Balogun 01:38:45 54 of 85 0 After talking to a client, the health care provider tells the nurse that the client's signature is needed on the consent form that has been completed. While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy." What action should the nurse take?

B. Provide educational materials about low-fat diet options

A client at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 proteinuria, and moderate peripheral edema. Immediately after hospital admission she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effectt?

B. Seizure activity stops

A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse Im so glad you are here. I think my baby has a dirty diaper. I cant change it as well as you can. Will you change my babies diaper for me? What is the nurses best response?

B. Suggest that t eh mother change the diaper as the nurse watches.

The nurse makes a home visit to a client with Alzheimer's disease. While reviewing the clients home care needs the client's spouse states, Its hard to see my spouse worsen each day. Im not sure I can keep doing this alone anymore. Which response by the nurse is best?

B. Tell me about the care you provide in a typical day and its challenging.

The HCP remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially?

B. Tell the HCP to stop the comments

A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy?

B. The client boss has asked the client to represent the company at an upcoming convention

The parent of an 11th month old child calls the pediatric outpatient clinic and tells the nurse that the child was exposed to measles two days ago during a family trip to the theme park which best response by the nurse

Bring the baby into the clinic for the measles mumps and rubella vaccine

123

Bullying is not a normal part of childhood it in growth and development

The nurse reviews the admission history of a 70yr old client diagnosed with COPD. Which of the following statements by the client does the nurse recognize as contributing to the development of COPD?

C and E

The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include?

C,D,E

The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time?

C. Have the spouse leave the room so that the client can be spoken with and examined in private.

The nurse is preparing to flush a clients central venous catheter. Which size syringe is best for the nurse to choose?

C. 10 ml

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hr newborn, which clinical finding requires the nurse to intervene?

C. Jitteriness

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?

C. Client with epilepsy puts on call light and reports having an aura

The nurse is caring for 4 hospitalized clients. Which should the nurse see first?

C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain

The nurse responds to the call light o f a patient with COPD, who says they cant breathe. The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?

C. Coach the client through controlled breathing exercises.

The nurse is providing care to a client experiencing post traumatic stress disorder following a terrorist attack at the clients place of worship. What is the priority nursing action?

C. Encourage The client to talk about the trauma.

A client with mitral valve prolapse has been experiencing occasional palpitations, light headedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse reinforce for this client.

C. Stay well hydrated and avoid caffeine

The registered nurse is preparing to administer oxytocin to induce labor in a client. The practical nurse assists the registered nurse and recognizes that the oxytocin infusion can lead to which of the following conditions?

C. Fetal distress and ceresean section

An elderly client is admitted with an acute exacerbation of COPD. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using the accessory muscles to breathe.

C. IV morphine 2 mg now, may repeat every 2 hours.

The client screams at the nurse you are all incompetent here. I have been waiting for 2 hours. How should the nurse respond initially?

C. It is upsetting to wait so long. How can I best help you?

A client with a diagnosis of antisocial personality disorder was given a 2 hr pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, Its all the nurses fault. The nurse was right there and did not remind me to sign in. What is the best response by the nurse?

C. It is your responsibility to sign in when you return from a pass.

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the UAP who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate?

C. Lets go together to ask about the clients cocerns.

The nurse provides teaching for a client newly prescribes disulfram for alcohol abstinence. Which information is the priority for the nurse to include?

C. List of everyday items containing hidden alcohol.

The nurse is assisiting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate?

C. Magnesium

A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?

C. My aunt has come over everyday to care for the baby because the baby's cries bother me.

The nurse is reinforcing teaching to the parent of a child recently diagnosed with attention-deficit hyperactivity disorder, combined type. Which statement by the parent requires intervention?

C. My child will outgrow this disorder around age 20.

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome?

C. My mother could not drive me here today, so I took the bus.

NCLEX-PN TEST - Kehinde Balogun 01:38:31 53 of 85 0 The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?

C. Notifying the hospital administration about the situation

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle continuous bubbling.

C. Suction control chamber

The nurse responds to a call for help from another staff member. Upon entering the clients room, the nurse observes an UAP performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority.

C. Obtain the defibrillator and apply the pads to the clients chest.

After a client with alzheimer's disease is found wandering in the middle of the street at 3:00 am and returned by police, the nurse reinforces teaching to family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction?

C. Place a chain lock on the door above or below the clients eye level

The spouse brings a client to an extremely busy emergency department due to erratic behavior and expressions of despair. When the triage registered nurse asks if the client feels suicidal now, the client shrugs and the shoulders. Based on these findings, the practical nurse expects to be assigned which nursing responsibility?

C. Place the client in an inside hallway with one-on-one observation

When unlicensed assistive personnel assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit falls over and cracks. The UAP immediately reports to the nurse. What is the nurses immediate action.

C. Place the distal end of the tube into a bottle of sterile saline

A native american client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on her. Which on the following is the best action by the nurse

C. Plan a meeting with the hcp, family, nurse. and medicine healer to make arrangements for the ceremony

The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first.

C. Potassium chloride IVPB once

The nurse is caring for a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience

C. Practices stress reduction techniques daily

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?

C. Prepare intubation and suction supplies at the bedside.

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by a fractured ribs. Where would the nurse observe an air leak?

C. Section C

A graduate student, who has been studying for final exams and using energy drinks to stay awake comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm?

C. Sinus rhythm with premature ventricular contractions

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow up?

C. Small tuft of hair at the base of the spine.

The health care provider remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should

C. Tell the HCP to stop the comments

The nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation?

C. Tell the charge nurse of the impending need to leave and that client coverage is required

The nurse on the mental health unit receives a report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?

C. That song is a message sent to me in secret code

The student nurse observes the respiratory therapist preparing to draw an arterial blood gas from the radial artery. The RT performs the Allens test and the student asks why this test performed before the blood sample is drawn. Which statement made by the rt is most accurate.

C. The allens test is done to determine the patency of the ulnar artery

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention.

C. The client has new dependent edema of the feet.

The nurse is speaking with the spouse of client following a family discussion with the health care provider about the clients terminal condition and eligibility for hospice care. The spouse states, I don't think I can make this donation right now. What would you do. How would the nurse respond?

C. These decisions are challenging. Tell me your spouses beliefs about about end-of-life.

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse," If I hadn't come home early from work, my spouse would be dead. I cant believe this is happening. What is the best response by the nurse?

C. This has been very overwhelming for you. What are you feeling right now.

A client with a history of obsessive compulsive personality disorder is seeking treatment for a gastrointestinal disorder and is schedules for a colonoscopy at 10 am. Due to a computer glitch, the procedure is postponed to 3 pm Which response would be characteristic of an individual with OCPD

C. This is unacceptable. I had my whole day planned out

A client diagnosed with pneumonia is experiencing shortness of breath, chest pain, and orthopnea. The chest x-ray reveals a very large right pleural effusion. Which intervention should the nurse anticipate for this client.

C. Thoracentesis

The nurse working in the intensive care unit hears an alarm coming from a clients room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm.

C. Ventricular Fibrillation

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder. She says to the nurse, "Its all my fault. I should have known not to accept a drink from someone I just met in a bar". What is the nurses best response?

C. You could not have anticipated the rape. You did not deserve or ask for it.

The practical nurse assists in the care of a client who was admitted in state of acute psychosis after ingesting illicit substances. The parent ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse?

C. Your child will have to remain here for observation until we know more

Of the abdominal lines shown in the exhibit, where would the nurse expect the fundal height of a 20 week gestation client to be felt?

C.C

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn. Which of the following lifestyle changes should the nurse recommend?

C.D

A nurse finds a client unresponsive and is unable to palpate a pulse. Resuscitation is initiated and continued by the rapid response team. The nurse then finds a do not resuscitate (DNR) prescription in the client's chart. What is the appropriate action by the nurse?

C.Immediately have the rapid response team stop resuscitation measures

Uses two words cannot hold a cup conceit self in a small tear

Central sulcus the second one

A client receiving total parents are all nutrition reports nausea abdominal pain and excessive thirst which is the best option for the nurse to take

Check the clients blood glucose

A child receives the varicella immunization the day after the injection in the pan calls the nurse to say that the child has discomfort slight redness in to verticals at the injection site what instructions to the nursery in force

Cover the vesicles with a small bandage until they are dry

The nurse is reinforcing teaching to a group of clients diagnosed with diabetes Molite us which lessons regarding **** yeah should be included

Cut toenails stayed across and file along the curves of the toes use a mild foot powder room for spring feet use cotton or lambswool to separate overlapping toes

A student nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The student nurse develops a nursing care plan and reviews it with the nurse preceptor before meeting with the client. Which of the following proposed nursing actions in the care plan requires intervention by the nurse preceptor.

D. Persuade the client to sign a contract promising not to commit suicide.

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?

D. Remain in the room with the client

The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse?

D. 32 weeks gestation client taking ibuprofen for moderate back pain.

A nurse is monitoring several clients in the medical-surgical unit. The nurse identifies which client as being at greatest risk for the development of delirium?

D. 80 yr old client with chronic obstructive pulmonary disease, chronic respiratory failure and urosepsis.

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says, good morning, and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take?

D. Remain silent and allow the client to leave.

The nurse is reinforcing discharge instructions to a postpartum client. Which instruction should the nurse include to promote newborn safety?

D. Remove pillows and loose blankets from the infants crib.

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?

D. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)

The nurse receives report on 4 clients. Which client should the nurse see first?

D. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?

D. Client with inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea and vomiting.

The practical nurse on the mental health unit is planning care with the registered nurse. Which client should be seen first?

D. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at caregivers.

A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?

D. Client with upper gastrointestinal bleed

The nurse is assisting with procedural moderate sedation at a clients bedside. The UAP comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?

D. Tell the UAP to inform the client in the next room that the nurse will be there shortly.

The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective.

D. I will shave with an electronic razor form now on.

The nurse is reviewing prescriptions for the assigned clients which prescription to the nurse question

Does Lycoming for a client with a history of irritable bowel syndrome who develops a postoperative paralytic Euless

The nurse is caring for a 10-yr old diagnosed with attention deficit hyperactivity disorder. In addition to the 3 core symptoms of ADHD which of the following would the nurse expect to find?

D. Low self esteem and impaired social skills.

A 62 yr old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority.

D. Performing a neurovascular check on the lower extremities.

A nurse is reinforcing discharge instructions to a client during the fifth hospitalization for pulmonary edema caused by congestive heart failure exacerbation. Which statement by the client indicates that further teaching is required?

D. Potato chips are an acceptable snack in moderation

A client with an implantable cardioverter defibrillator develops ventricular tachycardia with a pulse while admitted to the medical surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?

D. Prepare for synchronized cardioversion with the external defibrillator

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client?

D. Provide continuous one-to-one observation with the client

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?

D. Ranitidine 150 mg PO at bedtime

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

D. Refer employee to the employee's health care provider

The nurse caring for a client with an ileal conduit observes that the stoma appears bluish gray. What is the nurses best action

D. Report the findings to the health care provider immediately

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?

D. Right calf is 4 cm larger than left calf.

The nurse is reviewing the telemetry strips of assigned clients. The rhythm strip displayed in the exhibit is given to the nurse by the telemetry technicial. The nurse recognizes it as which rhythm?

D. Sinus Rhythm

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse reinforces teaching to the client that the pain will improve with which of the following?

D. Sitting up and leaning forward

A health care provider is screaming, why didn't you get surgery schedules sooner, at the nurse in the hallway. People in the hallway are staring. What is the initial reaction by the nurse?

D. State that the conversation needs to take place in private and walk to a room

A young client is diagnosed with major depressive mood disorder. Three weeks prior, the client fiance broke off their engagement, claiming the client was too fat and ugly. During one on one interaction with the nurse the client says," My fiance is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the best response by the nurse?

D. Tell me how you felt when your fiance broke up with you

D. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old

A client states, "I just don't know what to do about this situation with my parents, and the nurse replies, "I'm sure you will do the right thing. Which summary is true regarding the nurses response?

D. The response devalues the clients feelings and gives false reassurance.

The nurse is caring for a client with alcohol intoxication who is exhibiting nystagmus, ataxia, and confusion. Which prescription from the health care provider would the nurse expect to be implemented first?

D. Thiamine

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?

D. Third trimester client with right upper quadrant pain and nausea

A nurse is caring for a client following a forceps assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment the nurse notices a firm midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate.

D. Vaginal hematoma

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, The voices are bad today they are so angry with me. Which of the following is the best response by the nurse?

D. What are the voices saying to you

A client who was placed in restraints appears in the hallway an hour later and states, Im Houdini. I can get out of anything. There could be trouble now. Which of the following is the best response to this client?

D. What kind of trouble are you thinking about

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital acquires pneumonia and has been receiving intravenous antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

D. White blood cell count

A client recently diagnosed with schizophrenia is brought to the mental heath clinic by the identical twin sibling for the first follow-up visit after hospitalization. The clients sibling says to the nurse, I read that schizophrenia runs in families. I guess Im doomed. Which is the nurses response?

D. You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia.

A client on the locked unit of an impatient psychiatric hospital says to a nurse on the evening shift, During the day they let me out to go to the gift shop. Youre my favorite nurse: I know youll be a good sport and give me a pass. What is the best response?

D. You do not have privileges' for leaving the unit.

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time?

D. You should keep your feet apart and use a cane when walking

The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away. What is the best response by the nurse.

D. Your partner needs to be seen in the clinic today.

The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly report dizziness, and the nurse observes pallor and damp, cool skin. What would the nurse do first?

D.Turn the client to a lateral position

The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being the most at risk for suicide?

Divorced male client with parkinson disease who was recently laid off from his job.

The nurse is preparing to administer medications to a client with an asthma exacerbation. Which prescription should the nurse confirm with the health care provider to administration

Enoxaparin

The practical nurse is assessing the register nurse to care for a client receiving oxytocin for the induction of labor which of the following actions by the piano or appropriate during oxytocin infusion select all that apply

Evaluate fluid intake I'll put an input every four hours notify are in if less than five contractions of care in 10 minutes to obtain blood pressure with each oxytocin does change

The nurse is reinforcing teaching to a client with a hiatal hernia which statement by the client indicates further teaching as needed

Losing weight may reduce my reflux so I need to take a weightlifting class

The nurse is caring for a client with Chloe lying ass is in a cute Chloe cystitis the client suddenly vomits to 50 mL of greenish yellow emesis and reports severe right upper quadrant pain with radiation to the side shoulder which intervention would have the highest priority

Initiate NPO status

The nurse is collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation which of the following findings indicate diagnostic event evidenceOf pregnancy

Fetal heart tones detected by Doppler device and visualization of the fetus VI a ultrasound

Bullying is not a normal part of childhood it in growth and development

Go to the coin thing controlled breathing exercises

The practical nurse is assisting the register nurse with completing a health history have a client was expecting rheumatic fever which question is most important to ask the client in order to establish a diagnosis

Have you recently had a streptococcal throat infection

47-year-old client with polycystic ovary syndrome obesity and a history of unsuccessful in fertility treatments

High Fowlers

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with many other disease which statement by the client indicates a need for further teaching

I will need to restrict the amount of potassium in my diet

I need you to answer the length because we want to provide good Ryan care

I'll allow my child to have a snack while using HFCWO

The nurse is reinforcing teaching about a home in ministration of sub lingual nitroglycerin tablets to a claim and stable and Gina which statement by the clients indicates the nurse need for further teaching

I'll keep one bottle in the house and one in the car

The nurse cares for a client aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the clients heart murmur.

Left upper right

The nurse is administering medications to a client who is being evaluated for brain malignancy the client is scheduled for a CT scan with IV I'll die needed contrast in the next morning which medication to the nurse clarify with a healthcare provider

Met Formin

The emergency department nurse is caring for 70 all your client with a history of type two diabetes Molite us who reports sudden onset nausea sweating dizziness of the tea and the nurse at anticipate the ignition of which protocol

Myocardial infarction

The nurse is monitoring the client was suspected pulmonary tuberculosis which characteristic signs and symptoms does the nurse expect select all that apply

Night sweat purulent or blood tinged sputum and weight loss

The nurse at a mental health clinic is performing a suicidal screening on floor clients experiencing depression which client does the nurse recognize as being most depressed for suicide

One divorced client meal with Parkinson's disease who was recently laid off from his job

The nurse is preparing to administer 160 mg of Houston mind BIAIV piggyback to a client with chronic kidney disease and fluid overload the nurse plans to give the door slowly over 40 minutes to prevent

Otoxicity

A 62-year-old client admitted to the Telemann three unit after in the queue myocardial infarction three days ago reports that the left calf this very tender and warm to the touch what intervention is the priority

Performing a neurovascular check on the lower extremities

124

Pl. won a D pad on the chest in the other one on the back

The nurse is caring for a postoperative client with Hemovac dream which task of us quest is it inappropriate for the nurse to make the experience and license assistive personnel

Please change the sterile dressing on him about the drain insertion site when you both the client

The nurse is caring for a client after percutaneous placement of a coronary stand for mild cardio and function the client reads lower back pain as five on a scale of 0 to 10 and has blood pressure 140/92 the cardiac monitor shows normal sinus rhythm with occasional premature ventricular contraction and which prescription should the nurse administer first

Three

1,2,3,5

The nurse reviews a clients medical and notes the following Prn medication prescriptions acetaminophen haloperidol and be stepping. The nurse would administer a does of benztropine on assessing which client behavior(Muscle rigidity)

A client who fell and hit the head but refuses to go to the emergency department a client who needs prefilled insulin syringes a client with stage III pressure injury in need of the dressing change

Uses two words cannot hold a cup conceit self in a small tear

The nurse is evaluating a client understanding of post circumcision care for 20 for our own newborn circumcision was performed using the client method which statement by the client demonstrates a need for further teaching

Yellow accident on the glans penis indicate infection

The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn? 1. Choose an infant carrier with a narrow seat 2. Place 2 diapers on the infant at all times 3. Swaddle the infant with hips flexed and abducted 4. Use an infant swing that keeps both legs straight

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