Week 2/3 Practice Questions

D (automatically dispenses the drug)

Which drug delivery system most effectively reduces the likelihood of medication errors? a) unit-dose b) individual prescription c) floor stock d) automated

B, C, D

A nurse is performing an assessment on a neonate. Which assessment findings would indicate a metabolic response to cold stress? Select all that apply. a) arrhythmia b) hypoglycemia c) respiratory distress d) jaundice e) increase in blood pressure

D (indicate abruptio placentae, which decreases fetal oxygenation.) (B is only during postpartum period) (C would stimulate contractions, which would further the issue)

A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take? a) Ease the client's anxiety by assuring her that everything will be all right. b) Massage the client's fundus. c) Administer I.V. oxytocin, as ordered. d) Place the client on her left side and start supplemental oxygen, as ordered.

B (C - the appliance can be left in for 1w+ if no leakage) (A - not clamped but attached to leg bag @ night to allow adequate drainage)

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. What should the nurse do to prevent a urinary tract infection? a) Clamp the urinary appliance at night. b) Empty the urinary appliance before it is one-third full. c) Change the urinary appliance daily. d) Limit the client's walking with the appliance.

B (this is a rapid acting insulin so onset of 15 min. Could experience hypoglycemia if do not eat soon. Once pt located provide them either breakfast of 4 oz juice)

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? a) Send the nurse's assistant to the X-ray department to bring the client back to his room. b) Check the computerized care plan to determine what test was scheduled. c) Call the client's health care provider (HCP). d) Bring a small glass of juice, and locate the client.

C

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? a) laterally, from the distal area to the center c) in a widening circle around the drain, outward from the center d) laterally, from one side of the wound to the opposite side e) from the superior portion of the wound to the inferior

A (phrenic nerve in diaphragm)

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem? a) ineffective breathing pattern b) altered cardiac functioning c) alteration in level of consciousness d) alteration in urinary elimination

C (Do not mix with other drugs, avoid small veins r/t extravasation, RF cardioresp depression)

A physician orders diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true? a) It rarely causes adverse reactions. b) It may be mixed with other drugs in an infusion. c) It should be administered no faster than 5 mg/minute in an adult. d) It should be administered in a small vein to minimize irritation.

B

A birthing couple informs the nurse that they would like to have the placenta after the baby is born. What is the nurse's best response? a) "Why would you want to do that?" b) "Let me check about how to go about doing this." c) "Centers for Disease Control and Prevention policy does not allow the hospital to give the parents the placenta." d) "This should be a decision between the physician and couple."

C (want accurate I&O, pt might have heart failure and need to rest but want to maintain dignity)

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be most effective for this client? a) requesting an indwelling urinary catheter to avoid incontinence b) prescribing adult diapers for the client so she will not have to worry about incontinence c) placing a commode at the bedside and instructing the client in its use d) padding the bed with extra absorbent linens

A

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? a) a middle-aged man with no injuries who has rapid respirations and coughs b) a woman who is 5 months pregnant with no apparent injuries c) a 20-year-old with first-degree burns on her hands and forearms d) a 10-year-old with a simple fracture of the humerus who is in severe pain

A (Uncomplicated - normal grief response) (Dysfunctional - intense grief that doesn't result in reconciliation of feelings) (Disenfranchised - not openly acknowledged)

An older adult client has received a terminal lung cancer diagnosis. The client's adult children are tearful and afraid to leave their parent's bedside. What type of grieving is this family most likely experiencing? a) Anticipatory b) Dysfunctional c) Uncomplicated d) Disenfranchised

C

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value? a) "The BUN is decreased because your daughter is hypertensive." b) "The BUN is elevated because your daughter has hypoglycemia." c) "The BUN is elevated because your daughter is dehydrated." d) "The BUN is decreased because your daughter has developed hypothyroidism."

B (C would be side-lying) (Note it said perineal, which is why B is correct)

The client with colon cancer has an abdominal-perineal resection with a colostomy. To promote hygiene following surgery, what should the nurse do? a) Administer 30 mL of milk of magnesia to stimulate peristalsis. b) Assist the client with warm sitz baths. c) Maintain the client in a semi-Fowler's position. d) Remove the ostomy pouch as needed so the stoma can be assessed.

C

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? a) radial b) apical c) carotid d) brachial

B (dialysis has NO effect on hgb levels because some RBC are injured in the procedure, so dialysis can actually further anemia!) (Dialysis clears met wastes so electrolyte imbalances are restored)

Which abnormal blood value would not be improved by dialysis treatment? a) hypernatremia b) decreased hemoglobin concentration c) hyperkalemia d) elevated serum creatinine level

B (indicates hypoxia due to decreased circulating vol) (A is wrong b/c less than 100 ml/hr)

Which finding alerts the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? a) sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours b) restlessness and shortness of breath c) urine output of 180 mL during the past 3 hours d) increased blood pressure and decreased pulse and respiratory rates

B

A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which is the most appropriate step for the nurse to take to help the client? a) Refer the client to special interest clubs for newcomers. b) Support the client in developing attainable socialization goals. c) Have the client plan a social activity for the upcoming weekend. d) Model culturally appropriate interactional skills.

C, E

A refugee family from the Middle East arrives with enough food and supplies to have a party for their parent, who was admitted for depression. The nurse recognizes that which factors are in play? Select all that apply. a) Refugees who are not yet fully integrated into American culture are mistrustful and do not eat foods prepared by strangers. b) Dietary policy does not allow families to bring foods from outside the hospital for consumption. c) It is the practice in some Middle Eastern countries for families to supply food and linens for their hospitalized family member. d) A refugee family can be compared to a homeless family as both are used to carrying their belongings with them. e) Often, immigrant families cannot tolerate hospital food, or otherwise may prefer ethnic foods brought in from home.

C

The client tells the nurse that she stopped taking olanzapine 2 weeks ago because she is better and wants "to make it on my own without this darned medicine." What would be the nurse's most therapeutic response? a) "You've told me about other times like this when you stopped taking your medication and you got sick again. You should know better by now." b) "You're a smart girl. You know what will happen if you don't take your medication. Why do you want to stop?" c) "I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?" d) "Maybe you're ready for a short holiday from the olanzapine. I'll talk it over with the health care provider. But you need to keep taking it until I talk with your health care provider."

B

A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication? a) metabolic acidosis b) metabolic alkalosis c) respiratory alkalosis d) respiratory acidosis

A, C, E

A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply. a) Initial the vial as the person reconstituting the medication. b) Leave the vial in the client's room for easy access. c) Label the vial with the strength of the medication. d) Demand the pharmacy department mix all future doses. e) Store the multi-dose vial in a secure place.

D (used to tx growth deficiency - human growth hormone) (A & C are for diabetes insipidus) (A is adrenal insufficiency)

A parent brings in a school-age child to the clinic for treatment. The child is small in stature, but body parts are in proportion. Which pharmacological treatments does the nurse anticipate instructing the parent about? a) vasopressin b) synthetic adrenocorticotropic hormone c) desmopressin d) somatrem

C

Caregivers of an infant with a feeding button style gastrostomy tube mention to the nurse there is leaking present. What action should the nurse take? a) Ask caregivers to demonstrate how they hook up the tube to the feeding button. b) Reassure caregivers that some leakage is expected and apply barrier cream. c) Assess if the leakage is coming from valve failure or from the peristomal area. d) Teach the caregivers how to use gauze around the button to absorb leakage.

B

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain? a) irrigating it with normal saline b) compressing it and then plugging it to establish suction c) connecting it to low intermittent suction d) connecting it to a drainage bag and clamping it off

B

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? a) Impaired urinary elimination b) Deficient fluid volume c) Imbalanced nutrition: Less than body requirements d) Excess fluid volume

B (C may be done but it is not sufficient evidence)

The client with pyelonephritis asks the nurse, "How will I know whether the antibiotics are treating my infection?" What should the nurse tell the client? a) "When your symptoms disappear, you'll know that your infection is gone." b) "Your health care provider will take a urine culture." c) "Your health care provider can tell by the color and odor of your urine." d) "After you take the antibiotics for 2 weeks, you won't have any infection."

D

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? a) 16 breaths/min and deep in character b) 18 breaths/min and inhaled through the mouth c) 20 breaths/min and shallow in character d) 28 breaths/min and audible

C

What is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? a) Establish normal bowel and bladder function. b) Explain the experience of having delirium. c) Regain orientation to time and place. d) Resume a normal sleep-wake cycle.

C (pv loss of F&E, nutrients and meds)

When measuring gastric residual volume in a client receiving continuous tube feeding through a gastrostomy tube, the nurse attaches a large syringe to the tube and withdraws all fluid remaining in the stomach. After noting the amount of fluid, what should the nurse do? a) Discard the aspirated fluid down the toilet b) Add the aspirated fluid to the bag of formula c) Readminister the aspirated fluid through the feeding tube d) Discard the aspirated fluid into a biohazard container

C (think Painless = Previa)

When the nurse is assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which symptom would most likely alert the nurse that placenta previa is present? a) uterine tetany b) dull lower back pain c) painless vaginal bleeding d) intermittent pain with spotting

A (D is wrong b/c both canned carrots and milk can be high in sodium)

Which meal would be most appropriate for an adolescent with glomerulonephritis with severe hypertension? a) baked chicken, rice, beans, orange juice b) egg noodles, hamburger, canned peas, milk c) hot dog on a bun, corn chips, pickle, cookie, milk d) baked ham, baked potato, pear, canned carrots, milk

C ("The client's labor was under 3 hours in length, which meets the definition for precipitous labor. This increases the risk for postpartum hemorrhage but decreases the risk for infection")

The nurse is caring for a woman who gave birth vaginally to a healthy 6 pound (2.72 kg) newborn after a 2-hour labor at 37 weeks gestation. For which complication will the nurse assess as a priority due to the increased risk in this client? a) postpartum infection b) delay in lactation c) postpartum hemorrhage d) delayed infant bonding

B

The mother of a 10-year-old girl with diabetes asks the nurse's advice about whether or not her child, who has always been compliant with treatment, should be allowed to go trick-or-treating on Halloween with several friends. The nurse should tell the mother: a) "Yes, just give her a little extra insulin before she goes." b) "Yes, she needs to be with friends and do the things other children do." c) "You must go with her and watch her so she doesn't eat any sweets." d) "No, it would be a life-threatening emergency if she ate sweets."

B

The nurse has instructed the client about the correct positioning of the leg and hip following hip replacement surgery. Which statement indicates that the client has understood these instructions? a) "I can sit in any chair that I find comfortable." b) "I should avoid bending over to tie my shoes." c) "I should avoid any unnecessary walking for about 3 months after my surgery." d) "I may cross my legs as long as I keep my knees extended."

D (Crackles indicate pulmon edema, HR displays compensation)

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which condition? a) a hypoglycemic reaction b) cardiogenic shock associated with heart block c) acute renal failure d) development of congestive heart failure

D

The nurse is caring for a 3-year-old child with iron deficiency anemia and providing dietary instructions to the parents. Which of the following should be a priority for the nurse to include in the teaching? a) urging pasta with tomato sauce b) insisting on a banana each day c) encouraging milk products d) recommending lean meats

D (typical complications = contractures, pressure ulcers and resp inf)

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: a) dry mouth. b) ascites. c) fluid overload. d) contractures.

D

Which measure should a home healthcare nurse implement to minimize the potential for lawsuits? a) Have the client sign a waiver prior to the entry phase of a visit. b) Integrate the client's learning needs and goals into plans of care. c) Apply more conservative interventions than those used in a hospital setting. d) Perform thorough, accurate, and timely documentation.

A (normal for concern that baby will be lost in 3rd trimester) (B & D = second trimester) (C = 1st trimester)

While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, the nurse expects which feelings? a) vulnerability b) confirmation c) ambivalence d) body image disturbance

October 10

A client comes to the office for her first prenatal visit. She reports that January 3 was the first day of her last menstrual period. According to Naegele's rule, what date should the nurse record as the estimated date of delivery (EDD)? December 10 November 10 October 10 September 10

A

The nurse is caring for a 9-month-old infant with severe diarrhea that has lasted 3 days and who displays evidence of severe dehydration with increased heart rate and decreased blood pressure. What nursing assessment is a priority? a) capillary refill time b) skin turgor c) intake and output balance d) willingness to drink

D

The nurse is reviewing laboratory values on a client with heart failure and atrial fibrillation. The client has a potassium level of 2.8 mEq/L (2.8 mmol/L). The client is scheduled to receive their 0900 dose of digoxin. What is the nurse's best action? a) Review the dietary needs of the client and consult the dietitian. b) Give half of the digoxin and offer potassium-rich foods all day. c) Draw a stat potassium level and compare the earlier result with the current result. d) Withhold the dose of digoxin and notify the healthcare provider. e) Administer the dose of digoxin and offer the client a banana with breakfast.

A, B, D, E

The nurse is teaching a group of adolescents about proper nutrition. The nurse should explain that during this phase of development, it is necessary to increase intake of which nutrients? Select all that apply. a) protein b) iron c) grain d) calcium e) vitamin D

C

A nurse is caring for a male client who has gonorrhea. Which statement indicates that the client needs additional instruction? a) "I will practice safe sex at all times." b) "The infection can affect my heart or bloodstream." c) "It is not possible to be contagious as long as I take all of my antibiotics as prescribed." d) "The medication may cause nausea and vomiting."

A, D, E

A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. a) assistance with range of motion exercises for a client diagnosed with Alzheimer's disease b) education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis c) assessment of a client who has just returned from the postanesthesia care unit d) vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip e) administering a sitz-bath to a client who has had perineal surgery 2 days ago

D (battery - intentional and wrongful physical contact with a person that entails injury or offensive touching. Ex: lack of consent and doing tx)

A client admitted to the mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of what? a) malpractice b) negligence c) withdrawal d) battery

C

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse? a) Answer the client's question regarding the surgery. b) Contact the anesthesiologist and request a delay of surgery. c) Contact the surgeon to answer the client's question. d) Ask the circulating nurse to inform the surgeon of the client's question.

A, D, E, F (cannot do IVP or hang blood)

The nurse is co-assigned with a licensed practical/vocational nurse (LPN/VN) to care for 20 clients on a skilled, long-term care facility. When working as a team, which nursing duties would the nurse delegate to the LPN/VN? Select all that apply. a) Insert a 20 French Foley catheter. b) Inject furosemide 40 mg intravenously daily. c) Hang 2 units of packed red blood cells. d) Calculate output every 8 hours and report to the health care provider. e) Place a nasogastric tube for gastric decompression. f) Administer morphine sulfate 30 mg intramuscular every 4 hours as needed.

A ("Nurses can refuse to care for clients on several grounds such as moral conflict, feeling unsafe, or lacking the skills needed to safely deliver care. The nurse cannot refuse care based on the client's health concerns.")

The nurse manager is preparing to meet with several registered nurses (RNs) in the department to address practice issues. Which behavior by an RN will the nurse manager address as a violation of the RN's "duty to care"? a) declined assignment to care for a client with dementia who was incontinent of stool b) fabricated assessment results in the medical record for an admitted client c) shared confidential information about a hospitalized client on social media d) administered medications to a client in error that were intended for the client's roommate

D

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? a) Support the client's use of acetaminophen to relieve pain. b) Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. c) Discuss nutritional strategies to decrease the possibility of heartburn. d) Refer the client to her health care provider for evaluation and treatment of the pain.

B (resp acidosis)

The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of arterial blood gas values does the nurse expect for this client? a) pH 7.29 PaCO2 36, HCO3 19 b) pH 7.25, PaCO2 48, HCO3 24 c) pH 7.35, PaCO2 46, HCO3 30 d) pH 7.30, PaCO2 28, HCO3 16

A ("The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used")

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure? a) The student nurse irrigates the NG tube through the blue air vent port. b) The student nurse disconnects the suction tubing from the NG tube. c) The student nurse puts on clean gloves instead of sterile gloves. d) The student nurse allows the fluid in the syringe to flow by gravity into the NG tube.

A

The nurse is preparing to administer a preoperative medication that includes a sedative to a client who is having abdominal surgery. What should the nurse do first? a) Have the client empty the bladder. b) Ensure that the operative area has been shaved. c) Make sure the client is covered with a warm blanket. d) Have the family present.

A (have resp acidosis with hypoxia) (albuterol is a quick acting bronchodilator while ipratropium is a maintenance tx for bronchospasm that can be used w/ albuterol)

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first? a) albuterol nebulizer b) sputum culture c) ipratropium inhaler d) chest X-ray

B (When a mother is Rho(D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen)

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? a) Injection of Rho(D) immune globulin to the mother during her 6 week follow-up visit b) Administration of Rho(D) immune globulin I.M. to the mother within 72 hours c) Administration of Rho(D) immune globulin I.M. to the neonate within 72 hours d) Administration of Rho(D) immune globulin I.M. to the mother within 3 months

B

A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will a) feel that the bladder is smooth. b) palpate the bladder above the symphysis pubis. c) palpate the bladder at the umbilicus. d) be unable to palpate the bladder.

A, B, D, E

A young, healthy client comes to the clinic and reports having two to three nosebleeds each week and bruising very easily. After taking an in-depth history, the nurse asks the client for a list of any alternative or complementary modalities (CAM) that she uses. Which of the CAM items may predispose the client to this bleeding problem? Select all that apply. a) ginger powder b) green tea extract c) valerian root d) garlic capsules e) grapeseed extract

C (burping frequently helps relieve discomfort of air in stomach which is common with colic)

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action? a) placing the infant prone after the feeding b) holding the infant prone while feeding c) burping the infant during and after the feeding d) holding the infant in her lap to burp

B (Eyelid and extraocular muscles frequently affected = RF corneal abrasion if eyelids don't close completely)

The nurse is discussing discharge instructions with a client with myasthenia gravis who is taking pyridostigmine. What should the nurse instruct the client to do? a) Avoid contact with crowds. b) Administer artificial tears. c) Take pyridostigmine in the afternoon. d) Decrease protein in the diet.

B (produces heat which helps dissolve med. Shaking could cause med breakdown which would alter its MOA)

The nurse is reconstituting a powdered medication in a vial. After adding the solution to the powder, the nurse should a) invert the vial and let it stand for 2 to 3 minutes. b) roll the vial gently between the palms. c) shake the vial vigorously. d) stir the liquid with a sterile applicator.

B (RF SJ Synd)

The parents of a child on sulfamethoxazole and trimethoprim for a urinary tract infection report that the child has a red, blistery rash. What instructions should the nurse give the parents? a) Apply an anti-itch lotion to the affected areas at least twice a day. b) Discontinue the medicine and come for immediate further evaluation. c) Use sunblock and avoid midday sun while on the medication. d) Increase the child's fluid intake to at least 2,500 mL per day.

C

When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery? a) Bowel sounds are hypoactive on auscultation. b) The client says that she is hungry. c) The client passes flatus. d) Peristalsis can be felt on abdominal palpation.

D (indicates aspiration)

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? a) inability of the client to receive a rapid flow of the feeding b) a passage of flatus pre- and post-feeding c) intermittent epigastric tenderness d) formula in the client's mouth during the feeding, and increased cough

A (Goodell = probable sign of pregnancy where cervix softens, Hegar's sign = probable sign of pregnancy where uterus softens)

While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding? a) Chadwick's sign b) melasma c) Hegar's sign d) Goodell's sign

A

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer? a) "My cough has changed from a dry cough to one with lots of sputum production." b) "My voice is hoarser than it used to be." c) "I've lost 10 pounds (4.5 kg) in the last month." d) "I've had a low-grade fever for 2 weeks."

D (unless danger to self or others, can't force meds)

A client in an acute care mental health program refuses a morning dose of an oral antipsychotic medication and believes it contains poison. The nurse should respond by taking which action? a) omitting the dose and trying again the next day b) administering the medication by injection c) crushing the medication and putting it in the client's food d) consulting with the physician about a care plan.

C

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a) infusing I.V. fluids rapidly as ordered b) encouraging increased oral intake c) restricting fluids d) administering glucose-containing I.V. fluids as ordered

D (stools may also contain mucus and pus)

A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for: a) steatorrhea. b) alternating periods of constipation and diarrhea. c) constipation. d) bloody, diarrheal stools.

A

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate? a) enlarged breast tissue b) soft skin c) weak sucking response d) vernix caseosa

B ("The nurse has already attempted to explain the importance of staying, so the next step would be to notify the healthcare provider who should then reinforce the need to stay for an evaluation")

A client is being treated in the emergency department for a leg wound and has been impatient about the wait. The nurse explains how the triage process works and the importance of being assessed. The client tells the nurse, "I am not waiting around here any longer. My leg is fine." What is the best response by the nurse? a) Alert security immediately about the client's potential exit. b) Notify the healthcare provider of the client's intent to leave. c) Give the client permission to leave at any time. d) Ask the client if a sedative is needed for relaxation.

A (Hypothyroidism s/s: Fatigue, personality changes, edema, impaired memory, cold intol, dry skin, slowed speech, muscle weakness, wt GAIN, hair loss, constipation)

A client is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom? a) fatigue b) weight loss c) corneal abrasion d) diarrhea

C (not D r/t RF infection, A not necessary, B is true but not priority)

A client is diagnosed with pyelonephritis. Which nursing action is a priority for care now? a) Monitor hemoglobin levels. b) Stress the importance of the use of long-term antibiotics. c) Ensure sufficient hydration. d) Insert a urinary catheter.

A, B, E

A spouse brings the client to the emergency department. The spouse reports that since the death of their 7-month-old daughter 8 weeks earlier, the client has been neglecting the housework and family, has lost 20 lb (9.1 kg), and has not left the house. Which additional assessment findings would indicate to the nurse that the client may be experiencing extreme depression? Select all that apply. a) obvious neglect of personal hygiene b) inconsolable weeping c) meticulously folding clothes to place in the drawer d) discussing how beautiful the daughter was e) speaking in soft monotone voice

C (In recuperation phase, pt has suffered through hardest part and now is sensitive to image and self-esteem)

The nurse provides care to a client with severe burns. During the recuperation phase, the client becomes withdrawn. For what potential contributor to the client's change in demeanor should the nurse assess? a) decrease in coping abilities b) dependence and unwillingness to be discharged c) changes in body image and self-esteem d) pressure from family and friends to be more social

A (high phos foods = dairy products, bran, organ meats, fish, dried beans and peas)

A client on a low-phosphate diet receives a breakfast tray that includes scrambled eggs, cream of wheat cereal, strawberries, coffee, and low-fat milk. What is the nurse's best action? a) Remove the milk carton from the tray. b) Order the client a new breakfast tray. c) Replace the strawberries with an apple. d) Explain to the client why the eggs cannot be eaten.

B (concern for hemorrhage r/t biopsy)

A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make? a) Percuss the bladder for distention. b) Assess urine for excessive bleeding. c) Obtain a urine specimen for culture. d) Assess the patency of the Foley catheter.

C (key VS here is temp, not BP)

A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's prognosis? a) 3 days after the incident b) as soon as cardiopulmonary resuscitation is successfully initiated c) when the client's blood pressure has stabilized d) as soon as the client is warmed

D (B = FAS)

A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find a) congenital defects such as limb anomalies. b) a flattened nose, small eyes, and thin lips. c) lethargy 2 days after birth. d) irritability and poor sucking.

B (A is warfarin, c is used to control local bleeding, d is used with low BP/shock)

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? a) phytonadione (vitamin K) b) protamine sulfate c) thrombin d) plasma protein fraction

A (B not indicated b/c may cause bronchospasm)

A client, diagnosed with asthma, is experiencing an anaphylactic reaction to a medication. After administering initial emergency care, the nurse would a) administer bronchodilators. b) administer beta-adrenergic blockers. c) have the client lie flat in the bed. d) obtain serum electrolyte levels.

C (spec gravity elevated = indicates dehydration)

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results: pH 6.8, RBC 3 per high power field, color yellow, spec gravity 1.030. What should the nurse do next? a) Withhold the next dose of antihypertensive medication. b) Encourage the client to eat at least half of a banana per day. c) Encourage the client to increase fluid intake. d) Restrict the client's sodium intake.

B (antiviral) (Rest are antifungals)

A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? a) "Apply sulconazole nitrate twice daily by massaging it gently into the lesions." b) "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." c) "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." d) "Apply one applicator of terconazole intravaginally at bedtime for 7 days."

D

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) semiconsciousness b) hyperventilation c) delirium d) hypoxia

D ("reactive nonstress test is a positive sign indicating that the fetus is doing well at this point in the pregnancy. For a nonstress test to be a reactive test, at least two accelerations (15 beats or more) of the fetal heart rate lasting at least 15 seconds must occur after movement. If the fetus were compromised, the nonstress test would demonstrate no accelerations in fetal heart rate")

A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, "What does that mean?" The nurse explains that a reactive nonstress test indicates which of the following about the fetus? a) Evidence of late decelerations occurring during the test. b) Evidence of some compromise that will require birth soon. c) No accelerations demonstrated within a 20-minute period. d) Fetal well-being at this point in the pregnancy.

D

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? a) The facility will report the incident to the state board of nursing for disciplinary action. b) The incident will be documented in the nurse's personnel file. c) The nurse will be suspended and, possibly, terminated from employment at the facility. d) The incident report will provide a basis for promoting quality care and risk management.

A, C

A nurse is caring for a 14-year-old client who was admitted with cellulitis and has been ordered warm compresses. The nurse delegates the treatment to the unlicensed assistive personnel (UAP). The compress causes a first-degree burn to the area. Which actions should the nurse initiate? a) Notify the healthcare provider of the injury b) Document the injury describing the UAPs actions c) Complete an incident report regarding the event d) Place ice compresses on the injured area e) Initiate a disciplinary action toward the UAP

D

A parent calls the clinic to report their 9-month-old infant has had 5 soft to loose stools today, has a decreased appetite, but is alert and playing. Which advice is most appropriate for the nurse to give the parent? a) "Notify your infant's daycare of his illness." b) "Call back if your infant has 10 stools in 1 day." c) "Feed your infant clear liquids only." d) "Continue your infant's normal feedings."

B

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is which factor? a) the vital signs b) level of consciousness c) reactions of the pupils d) motor strength

B (may be a laceration or hematoma) (C & D are correct but not the priority)

A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated? a) reassuring the client that such pain is normal after vaginal birth b) assessing the perineum c) preparing a warm sitz bath for the client d) administering additional pain medications

D (resp alk)

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? a) Administer ordered supplemental oxygen. b) Offer the client fluids frequently. c) Administer an ordered decongestant. d) Instruct the client to breathe into a paper bag.

B

The parent of a school-age child with autism asks the nurse how she should tell her son that he has autism. Which response by the nurse is most therapeutic? a) "You should let the health care professionals tell your son about his diagnosis of autism." b) "Explain the definition of autism and emphasize your child's strengths as well as his areas of challenge." c) "Explain to your son that he has a developmental disorder that makes him different from other children his age." d) "Tell your son that he is different from other kids his age and that you will always be there to support him."