A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take?
A. Administer the feeding over 30 min.
B. Place the child in as supine position after the feeding.
C. Charge the feeding bag and tubing every 3 days.
D. Warm the formula in the microwave prior to administration.
A. Administer the feeding over 30 min.
- A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider?
A. Potassium level 4.2 mEq/L.
B. Apical pulse 58/min.
C. Digoxin level 1 ng/ml.
D.Constipation for 2 days.
B. Apical pulse 58/min
A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take?
A.Arrange for an ethics committee meeting to address the family’s concerns.
B. Support the family’s decision and initiate life-sustaining measures.
C. Complete an incident report.
D.Encourage the family to contact an attorney.
A. Arrange for an ethics committee meeting to address the family’s concerns.
A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take?
A. Store the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.
A. Store the glasses in a labeled case.
A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?
A. Remove the protective gown after the client’s room.
B. Place the client in a room with negative pressure.
C. Wear gloves when providing care to the client.
D. Wear a mask when changing the linens in the client’s room.
C. Wear gloves when providing care to the client.
A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?
A. Perform an ECG every 12 hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.
D. Obtain a cardiac rehabilitation consultation.
The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives?
A. Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
D. Hypocalcemia
B. Thrombophlebitis.
A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client’s understanding of life-sustaining measures.
C. Determine the client’s preferences about post mortem care.
D. Request a conference with the client’s family.
B. Evaluate the client’s understanding of life-sustaining measures.
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
A. Substernal retractions.
B. Hematuria.
C. Temperature 37.9 C (100.2 F).
D. Sneezing.
A. Substernal retractions.
A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the .following action should the nurse take?
A. Instill 500 ml of solution through the NG tube.
B. Insert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on his right side.
B. Insert a large-bore NG tube.
A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority?
A. Psychologist.
B. Social worker.
C. Occupational therapist.
D. Speech-language pathologist.
D. Speech-language pathologist.
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider?
A. WBC count 8,000/mm3.
B. Platelets 150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. Erythrocyte sedimentation rate 75 mm/hr
D. Erythrocyte sedimentation rate 75 mm/hr
A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
A. Platelet count.
B. Potassium level.
C. Creatine clearance.
D. Pre-albumin.
A. Platelet count.
A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
A. Place an ice pack over the cast.
B. Palpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.
B. Palpate the pulse distal to the cast.
A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply)
A. Keep objects in the client’s room in the same place.
B. Ensure there is high-wattage lighting in the client’s room.
C. Approach the client from the side.
D. Allow extra time for the client to perform tasks.
E. Touch the client gently to announce presence.
A. Keep objects in the client’s room in the same place.
B. Ensure there is high-wattage lighting in the client’s room.
D. Allow extra time for the client to perform tasks.
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles?
A. MEDLINE
B. CINAHL.
C. ProQuest.
D. Health Source.
B. CINAHL.
A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first?
A. Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. Administer 100% humidified oxygen.
D. Administer 100% humidified oxygen.
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
A. Place food on the left side of the client’s mouth when he is ready to eat.
B. Provide total care in performing the client’s ADLs.
C. Maintain the client on bed rest.
D. Place the client’s left arm on a pillow while he is sitting.
D. Place the client’s left arm on a pillow while he is sitting.
A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
A. Confront the client about this behavior.
B. Express sympathy for the client’s situation.
C. Speak assertively to the client.
D. Stand within 30 cm (1 ft) of the client when speaking with them.
C. Speak assertively to the client.
A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
A. Cleanse equipment before removal from the client’s room.
B. Limit the client’s visitors to 30 min per day.
C. Discard the client’s linens in a double bag. D. Discard the radioactive source in a biohazard bag
B. Limit the client’s visitors to 30 min per day.
A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?
A. Frothy, pink sputum.
B. Jugular vein distention.
C. Weight gain.
D..Bradypnea
A. Frothy, pink sputum.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin.
A. Diabetes mellitus.
B. Shoulder presentation.
C. Post term with oligohydramnios.
D. Chorioamnionitis
C. Post term with oligohydramnios.
A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make?
A. “Your baby needs an IV because she is not producing any tears”
B. “Your baby needs an IV because her fontanels are budging”
C. “Your baby needs an IV because she is breathing slower than normal”
D. “Your baby needs an IV because her heart rate is decreasing”
A. “Your baby needs an IV because she is not producing any tears”
A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
A. “Taking furosemide can cause your potassium levels to be high”
B. “Eat foods that are high in sodium”
C. “Rise slowly when getting out of bed”
D. “Taking furosemide can cause you to be over hydrated”
C. “Rise slowly when getting out of bed”
A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?
A. Allow the client enough time to perform rituals.
B. Give the client autonomy in scheduling activities.
C. Discourage the client from exploring irrational fears.
D. Provide negative reinforcement for ritualistic behaviors.
A. Allow the client enough time to perform rituals.
A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?
A. Serotonin syndrome
B. Tardive dyskinesia
C.Pseudo parkinsonism.
D. Acute dystonia.
A. Serotonin syndrome
A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?
A. Low back pain.
B. Dyspnea.
C. Hypotension.
D. Thready pulse.
B. Dyspnea.
A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April 12. Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.)
0119 date
A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group?
A. The group is organized in an autocratic structure.
B. The group encourages members to focus on a particular issue.
C. The group must be led by a licensed psychiatrist.
D. The group encourages clients to form dependent relationships.
B. The group encourages members to focus on a particular issue.
A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching.
A. “OOB with assistance for breakfast”
B. “Given 2 mg MSO4 IM for report of pain”
C. “Dressing changed qd”
D. “Administered 8 u regular insulin sq.”
D. “Administered 8 u regular insulin sq.”
A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- Apply pressure to the lacrimal punctum.
- Ask the child to look upward.
- Pull the lower eyelid downward.
- Instill the drops of medication.
- Place the child in a sitting position.
- Place the child in a sitting position.
- Ask the child to look upward.
- Pull the lower eyelid downward.
- Instill the drops of medication.
- Apply pressure to the lacrimal punctum.
A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take?
A. Request an interpreter of a different sex from the client.
B. Request a family member or friend to interpret information for the client.
C. Direct attention toward the interpreter when speaking to the client.
D. Review the facility policy about the use of an interpreter.
D. Review the facility policy about the use of an interpreter.
A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
A. Urine output 20 ml/hr.
B. Montevideo units constantly 300 mm Hg.
C. FHR pattern with absent variability.
D. Contractions every 5 min that last 30 seconds.
C. FHR pattern with absent variability.
A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy?
A. Teaching parenting skills to expectant mothers and their partners.
B. Conducting mental health screenings at the local community center.
C. Referring client who have obesity to community exercise programs.
D. Providing crisis intervention through a mobile counseling unit.
A. Teaching parenting skills to expectant mothers and their partners.
A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?
A. Match the client’s blood type with the type and cross match specimens.
B. Confirm the provider’s prescription matches the number on the blood component.
C. Ask the client to state the blood type and the date of their last blood donation.
D. Ensure that the client’s identification band matches the number on the blood unit.
D. Ensure that the client’s identification band matches the number on the blood unit.
A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy?
A. “I have been experiencing more tremors in my left arm than before”
B. “I noticed that I am having a harder time holding on to my toothbrush”
C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground”
D. “Sometimes, I feel I am making a chewing motion when I’m not eating”
C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground”
A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect?
A. Increased creatine.
B. Increased hemoglobin.
C. Increased bicarbonate.
D. Increased calcium.
A. Increased creatine.
A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take?
A. “Did the doctor discuss with you that there was a change in this medication?”
B. “I recommend that you take this medication as prescribed”
C. “Do you know why this medication is being prescribed to you?”
D. “I will call the pharmacist now to check on this medication”
D. “I will call the pharmacist now to check on this medication”
A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?
A. Use three pronged grounded plugs.
B. Cover extension cords with a rug.
C. Check the tingling sensations around the cord to ensure the electricity is working.
D. Remove the plug from the socket by pulling the cord.
A. Use three pronged grounded plugs.
A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?
A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg.
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago.
C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.
D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a
dietitian
A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”.
B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain
potassium”.
D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”.
B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take?
A. Place the tip of the thermometer under the center of the infant’s axilla.
B. Pull the pinna of the infant’s ear forward before inserting the probe.
C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum.
D. Insert the thermometer in front of the infant’s tongue.
A. Place the tip of the thermometer under the center of the infant’s axilla.
A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include?
A. Children who have varicella are contagious until vesicles are crusted.
B. Children who have varicella should receive the herpes zoster vaccination.
C. Children who have varicella should be placed in droplet precaution.
D. Children who have varicella are contagious 4 days before the first vesicle eruption.
A. Children who have varicella are contagious until vesicles are crusted.
A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. Administer the medication.
D. Administer the medication.
A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer?
A. Pregabalin
B. Lorazepam
C. Colchicine
D. Codeine.
A. Pregabalin
A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
A. Prime IV tubing with 0.9% sodium chloride.
B. Use a 24-gauge IV catheter
C. Obtain filter less IV tubing.
D. Place blood in the warmer for 1 hr.
A. Prime IV tubing with 0.9% sodium chloride.
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate?
A. Looking at alphabet flashcards.
B. Playing with a large plastic truck.
C. Use scissors cut out paper shapes.
D. Watching a cartoon in the dayroom.
B. Playing with a large plastic truck.
A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make?
A. Coffee with creamer.
B. Lettuce with sliced avocados.
C. Broiled skinless chicken breast with brown rice.
D. Warm toast with margarine.
C. Broiled skinless chicken breast with brown rice.
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
A. Obtain the newborn’s body temperature using a tympanic thermometer.
B. FACES pain scale.
C. Auscultate the newborn’s apical pulse for 60 seconds.
D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence.
C. Auscultate the newborn’s apical pulse for 60 seconds.
A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take?
A. Insert an indwelling urinary catheter.
B. Apply fetal heart rate monitor.
C. Initiate fundal massage.
D. Initiate an oxytocin IV infusion.
B. Apply fetal heart rate monitor.
A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the
following findings should the nurse to report?
A. Chest pain
B. Muscle spasms.
C. Cool, moist skin.
D. Incisional pain.
A. Chest pain
A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating?
A. Quality improvement.
B. Patient (Unable to read)
C. Evidence based practice.
D. Informatics.
A. Quality improvement.
A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take?
A. Confront the nurse about the suspected alcohol use.
B. Inform another nurse on the unit about the suspected alcohol use.
C. Ask the nurse to finish administering medications and then go home.
D. Notify the nursing manager about the suspected alcohol use.
D. Notify the nursing manager about the suspected alcohol use.
A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?
A. Apply zinc oxide ointment to the irritated area.
B. (Unable to read)
C. Wipe stool from the skin using store bought baby wipes.
D. Apply talcum powder to the irritated area.
A. Apply zinc oxide ointment to the irritated area.
A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
A. “Staff will apply identification band after first bath”
B. “I will not publish public announcement about my baby’s birth”
C. “I can remove my baby’s identification band as long as she is in my room”
D. “I can leave my baby in my room while I walk in the hallway”
B. “I will not publish public announcement about my baby’s birth”
A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?
A. “Morphine 3 mg SQ every 4 hr. PRN for pain.”
B. “Morphine 3 mg Subcutaneous (Unable to read)
C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.”
D. “Morphine 3 mg SC q 4 hr. PRN for pain.”
B. “Morphine 3 mg Subcutaneous (Unable to read)
A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
A. Notify the provider.
B. Report the incident to the nurse manager.
C. Monitor vital signs.
D. Fill out an incident report.
C. Monitor vital signs.
A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
A. “Dehydration is treated with calcium supplements”
B. “Dehydration can increase the risk of preterm labor”
C. “Dehydration associated gastroesophageal reflux”
D. “Dehydration is caused by a decreased hemoglobin and hematocrit”
B. “Dehydration can increase the risk of preterm labor”
A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the
following client information should the nurse report?
A. (Unable to read)
B. (Unable to read)
C. Answer might be lower platelets.
D. (Unable to read)
C. Answer might be lower platelets.
A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?
A. Use the client’s children to provide interpretation.
B. (Answer was the nurse was going to do the interpretation)
C. Offer client’s translation services for a nominal fee.
D. Evaluate the clients’ understanding at regular intervals.
B. (Answer was the nurse was going to do the interpretation)
A nurse is preparing an in service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?
A. Leaving an NG tube clamped after administering oral medication
B. Documenting communication with the provider in the progress notes of the clients medical record.
C. Administering K via IV bolus
D. Placing a yellow bracelet on a client who is at risk of falls.
C. Administering K via IV bolus
A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?
A. Whole grain bread
B. Avocados
C. Smoked Salmon
D. Pepperoni pizza
A. Whole grain bread
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?
A. Attach the restraint to the bed’s side rails
B. Request a PRN restraint prescription for clients who are aggressive
C. Document the client’s condition every 15 min.
D. Remove the clients’s restraint every 4 hours.
C. Document the client’s condition every 15 min.
A charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min
B. A client who has cancer with a sealed implant for radiation therapy.
C. A client who is receiving heparin for DVT
D. A client who is 1 day postoperative following a vertebroplasty.
D. A client who is 1 day postoperative following a vertebroplasty.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
C. Swelling of the face
A nurse is developing a plan for a client who has schizophrenia and experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
A. Ask the client directly what is he hearing
B. Encourage the client to lie down in a quiet room
C. Avoid eye contact with the client
D. Refer to the hallucinations as if they were real
A. Ask the client directly what is he hearing
A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique?
A. Applying a sterile gown after applying a sterile mask
B. Balancing the bottle on the sterile basin while pouring the liquid
C. Placing the supplies on the sterile field and leaving a 1 inch perimeter
D. Putting on sterile gloves after preparing the sterile field.
B. Balancing the bottle on the sterile basin while pouring the liquid
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personal (AP). Which of the following actions should the nurse take first to manager her time effective?
A. Develop an hourly time frame for tasks
B. Schedule daily activities
C. Determine goals of the day
D. Delegate tasks to the AP
C. Determine goals of the day
A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?
A. I will decrease my daily protein intake to 15 grams per day
B. I will use ibuprofen as needed to control abdominal pain
C. I will take sucralfate with meals three times per day
D. I will avoid food and beverages that contain caffeine
D. I will avoid food and beverages that contain caffeine
A nurse is reviewing legal issues in health care with a group of newly licensed nurse. Which of the following recommendations should the nurse make?
A. Place copies of incident reports in clients medical records.
B. Overestimate clients acuity to prevent short staffing
C. Ensure that each client has a living will on file prior to treatment
D. Obtain personal professional liability insurance coverage
C. Ensure that each client has a living will on file prior to treatment
A nurse is providing preoperative teaching about patient controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?
A. The PCA will deliver a double dose of medication when you push the button twice
B. You can adjust the amount of pain you receive by pushing on the keypad
C. Continuous PCA infusions is designed to allow fluctuating plasma medication levels
D. You should push the button before physical activity to allow maximum pain control
D. You should push the button before physical activity to allow maximum pain control
A charge nurse is teaching a newly nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following should the charge nurse include?
A. The proxy should make health care decisions for the client regardless of the clients ability to do so
B. The proxy can make financial decisions if the need arises
C. The proxy can make treatments decisions if the client is under anesthesia
D. The proxy should manage legal issues for the client
C. The proxy can make treatments decisions if the client is under anesthesia
A nurse is caring for a client who has a history of depression and i experiencing a situational crisis. Which of the following actions should the nurse take first?
A. Confirm the clients perception of the event
B. Notify the clients support person
C. Help the client identify identify personal strengths
D. Teach the client relaxation techniques
A. Confirm the clients perception of the event
A nurse is caring for a client who has end stage kidney disease. The clients adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child medical history should the nurse identify as a contraindication to the procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary Glaucoma
C. Hypertension
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the clients TV privileges if he does not attend group therapy
C. Encourage the client to take frequent rest periods
D. Place the client in seclusion when he exhibits signs of anxiety
C. Encourage the client to take frequent rest periods
A nurse is working with a client who has anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
A. Lets talk about how you can change your response to stress
B. We should establish our roles in the initial session
C. Let me show you simple relaxation exercise to manage stress
D. We should discuss resources to implement in your daily life
B. We should establish our roles in the initial session
A staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper mechanics when lifting. Which of the following images indicates the appropriate use of ergonomic principles?
Legs apart, Bending the knees, straight back
A nurse is providing teaching to an older adult client about methods of promote nighttime sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall sleep
B. Take a 1hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime.
D. Eat a light snack before bedtime.
A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, I do not know what to do. Everything has been happening so quickly. Which of the following responses by the nurse is therapeutic?
A. Can you talk about what was happening with your partner at home?
B. Why do you think your partner symptoms are progressing so quickly?
C. You should make sure your partner takes the prescribed medication
D. You did the right thing by bringing your partner in for treatment
A. Can you talk about what was happening with your partner at home?
A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has a hip fracture and a new onset of tachypnea
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
B. A client who has a hip fracture and a new onset of tachypnea
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?
A. Consume food high in bran fiber
B. Increase intake of milk products
C. Sweeten foods with fructose corn syrup
D. Increase intake of foods high in gluten
A. Consume food high in bran fiber
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
C. Upper extremity hypotension
D. Increased ICP
A. Weak femoral pulses
A nurse is providing teaching to a client about adverse effects of sertraline. Which of the following adverse effects should the nurse include?
A. Excessive sweating
B. Increased urinary frequency
C. Dry mouth
D. Metallic taste in mouth
A. Excessive sweating
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100 /min for the past 15 min. The nurse identify which of the following conditions as a possible cause of fetal bradycardia?
A. Maternal fever
B. Fetal anemia
C. Maternal hypoglycemia
D. Chorioamnionitis
C. Maternal hypoglycemia
A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?
A. This test should be performed after your baby is 24 hours old
B. A nurse will draw blood from your babies inner elbow
C. Your baby will be given 2 ounces of water to drink prior to the test
D. This test will be repeated when your bay is 2 month old
A. This test should be performed after your baby is 24 hours old
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
A. I can not be a witness for your consent to donate
B. Your name can not be removed once you are listed on the organ donors list
C. Your desire to be an organ donor must be documented in writing
D. You must be at least 21years old to become an organ donor
C. Your desire to be an organ donor must be documented in writing
A nurse is caring for a client who is at 33 weeks gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
D. Contractions
A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?
A. Take Mg hydroxide for indigestion
B. Drink at least 3 L of fluid daily
C. Eat 1g/kg of protein per day
D. Consume foods high in K
C. Eat 1g/kg of protein per day
A charge nurse is teaching new staff members about factors that increase a clients risk to become violent. Which of the following risk factor should the nurse include as the best predictor of future violence?
A. Previous violent behavior
B. A history of being in prison
C. Experiencing delusions
D. Male gender
A. Previous violent behavior
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
A. Folate
B. Zinc
C. Iron
D. Calcium
A. Folate
A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client?
A. Peanut butter sandwich
B. Oatmeal with butter
C. Chicken noodle soup
D. Celery sticks
A. Peanut butter sandwich
A nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to following medications requires to follow facility procedure in the safety handling of a bio-hazardous material spill?
A. Doxorubicin hydrochloride
B. Ampicillin Sodium
C. Metronidazole
D. Phenytoin
A. Doxorubicin hydrochloride
A nurse in a providers office is reviewing a female clients medical record during a routine visit. The nurse should recommend increased dietary intake of which of the following vitamins?
A. Vit D
B. Vit K
C. Vit B12
D. Vit A
C. Vit B12
A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?
A. Ritualistic behavior
B. Suspicious of others
C. Exhibits separation anxiety
D. Preoccupied with aging
D. Preoccupied with aging
A nurse is caring for a child who has CF and requires postural drainage. Which of the following actions should the nurse take?
A. Hold hand flat to perform percussions on the child
B. Perform the procedure twice a day
C. Administer a bronchodilator after the procedure.
D. Perform the procedure prior to meals
D. Perform the procedure prior to meals
A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?
A. HR 58
B. Fasting blood glucose 100
C. Hgb 14
D. WBC 2900
D. WBC 2900
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
A. Limit your child K intake while she is taking this medication
B. You can add the medication to a half a cup of your child favorite juice
C. Repeat the dose if your child vomits within 1 hour after taking the medication
D. Have your child drink a small glass of water swallowing the medication
D. Have your child drink a small glass of water swallowing the medication
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?
A. This type of seizure can be mistaken for daydreaming
B. This type of seizure last 30 to 60 seconds
C. The child usually has an aura prior to onset
D. This type of seizure has a gradual onset
A. This type of seizure can be mistaken for daydreaming
A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a non healing leg ulcer
C. AN older adult client who has presbyopia
D. A client who has an albumin level of 3.7
B. A client who has a non healing leg ulcer
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client is at risk for aspiration?
A. Sitting in a high fowlers position during the feeding
B. A history of gastro esophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 ml 1 hr postprandial
B. A history of gastro esophageal reflux disease
A nurse is caring for several clients on a medical surgical unit. For which of the following nursing activities is it required that the nurse use sterile gloves?
A. Inserting a NG-tube
B. Administering total parenteral nutrition through a central venous access device
C. Initiating an IV
D. Performing tracheostomy care
D. Performing tracheostomy care
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist one. Which of the following responses should the nurse make?
A. We can provide a copy of your records, but the therapist notes are not included.
B. I do not think you will benefit from reviewing the therapist notes right now
C. Why are you interested in seeing the therapist notes?
D. Are you not happy with your treatment?
A. We can provide a copy of your records, but the therapist notes are not included.
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?
A. Monitor FHR via doppler every 30min
B. Restrict the clients total fluid intake to 250 ml/hr
C. Give the client protamine if signs of magnesium sulfate toxicity occur
D. Measure the clients urine output every hour
D. Measure the clients urine output every hour
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
A. Contractions lasting 80 sec
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Temp 37.4 (99.3)
B. FHR baseline 170/min
A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid
B. Have protamine sulfate available at the bedside
C. Reposition the client side to side each hour
D. Monitor the client for HTN
C. Reposition the client side to side each hour
A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse palm to take during the orientation phase of the relationship?
A. Determine previous coping skills used by the client
B. Establish the responsibilities of the nurse and client
C. Facilitate the clients problem solving skills
D> Assist the client in expressing alternative behavior
B. Establish the responsibilities of the nurse and client
A nurse is reviewing the medical record of 4 clients. The nurse should identify that which of the following client findings requires follow up care?
A. A client who received a Mantoux test 48 hr ago and has an induration
B. A client who is schedule for a colonoscopy and is taking sodium phosphate
C. A client who is taking warfarin and has an INR of 1.8
D. A client who is taking bumetanide and has potassium level of 3.6
A. A client who received a Mantoux test 48 hr ago and has an induration
A nurse is caring for a client who is 2 hour pos op following a cardiac catheterization. Which of the following is the priority assessment finding?
A. Report of burning sensation at the insertion site
B. Absence of pedal pulse in the affected extremity
C. Urinary output 25 ml/hr
D. SpO2 91%
B. Absence of pedal pulse in the affected extremity
A nurse in a mental facility receives change of shift report for 4 clients. Which of the following clients should the nurse plan to assess first?
A. A client placed in restraints due to aggressive behavior
B. A client who will be receiving her first ECT treatment today
C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
D. A newly admitted client who has a history of 4.5kg weigth loss in the past 2 months
A. A client placed in restraints due to aggressive behavior
A nurse is providing discharge teaching about a car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
A. I can turn my baby car seat around when she weighs 15 pounds
B. I can place my baby in the front seat with the airbag turned off
C. I will place my baby in a forward facing car seat in my back seat
D. I will position my baby at a 45 degree angle in the car seat
D. I will position my baby at a 45 degree angle in the car seat
A nurse in a clinic is assessing a 6 month old infant. Which of the following findings should the nurse report to the provider?
A. Pulse 140 min
B. Closed anterior fontanel
C. RR 26 min
D. Abdominal breathig
B. Closed anterior fontanel
- A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client’s peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client’s condition every 15 minutes
D. Document the client’s condition every 15 minutes
A nurse is developing an in service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
A. The clients exhibits impulse behavior
B. The client might act seductively
C. The client is exceptionally clingy to others
D. The client is overly concerned about minor details
A. The clients exhibits impulse behavior
A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take?
A. Monitor the dorsalis pedis pulse every 15 min
B. Keep the client NPO for 24 hours
C. Place the client in Fowlers position
D. Maintain struct bedrest for th first 12 hours
A. Monitor the dorsalis pedis pulse every 15 min
A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?
A. Peripheral neuropathy
B. Osteoarthritis
C. Abdominal aortic aneurysm
D. Phlebitis
A. Peripheral neuropathy
A nurse in an ED is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first?
A. Calculate fluid replacement based on VS and UOP
B. Determine the location and depth of the burns
C. Check the mouth for soot and smoky breath
D. Administer antibiotics prophylactically
C. Check the mouth for soot and smoky breath
A nurse is caring for a client following a stroke. The client has right sided weakness and facial drooping. Which of the following nursing actions is the priority?
A. Perform range of motion exercises to the clients extremities
B. Place the clients tight hand in a supination position
C. Change the clients position every 2 hours
D. Maintain NPO status for the client
D. Maintain NPO status for the client
A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit pf RBC. Which of the following actions should the nurse take?
A. Administer the blood via a 21 gauge IV needle
B. Set the IV infusion pump to administer the blood over 6 hours
C. Check the clients VS from the previous Shift prior to the initiation of the transfusion
D. Flush the blood administration tubing with NS prior to transfusion
D. Flush the blood administration tubing with NS prior to transfusion
Intra-dermal Injections areas.
A. Buttocks
B. Upper back
C. Hamstring
B. Upper back
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? SATA
A. Impulse control difficulty
B. Left Hemiplegia
C. Loss of depth perception
D. Aphasia
E. Lack of situational awareness
A. Impulse control difficulty
B. Left Hemiplegia
C. Loss of depth perception
E. Lack of situational awareness
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
A. Teach the client to scan the right to see objects on the right side of her body.
B. Place the bedside table on the right side of the bed.
C. Orient the client to the food on her plate using the clock method.
D. Place the wheelchair on the client’s left side.
B. Place the bedside table on the right side of the bed.
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? SATA
A. have suction equipment available
B. Feed client thickened liquids
C. Place foods on the unaffected side of the mouth
D. Assign an assistive personnel to feed the client slowly.
E. Teach the client to swallow with her neck flexed.
A. have suction equipment available
B. Feed client thickened liquids
C. Place foods on the unaffected side of the mouth
E. Teach the client to swallow with her neck flexed.
A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client’s plan of care? SATA
A. Speak to the client at a slower rate
B. Assist the client to use flash card with pictures
C. Speak to the client in a loud voice.
D. Complete sentences that the client cannot finish.
E. Give instructions one step at a time
A. Speak to the client at a slower rate
B. Assist the client to use flash card with pictures
E. Give instructions one step at a time
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception
C. Inability to recognize familiar objects
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of following actions should the nurse take?
A. Position the client in an upright position, leaning over the bedside table.
B. Explain the procedure.
C. Obtain ABG’s.
D. Administer benzocaine spray.
A. Position the client in an upright position, leaning over the bedside table.
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
B. Respiratory alkalosis
A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider?
A. Blood-tinged sputum
B. Dry, nonproductive cough
C. Sore throat
D. Bronchospasms
D. Bronchospasms
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room? SATA
A. Oxygen equipment
B. Incentive spirometer
C. Sterile dressing
D. Suture removal kit
E. Pulse oximeter
A. Oxygen equipment
C. Sterile dressing
E. Pulse oximeter
A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? SATA
A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the puncture site
A. Dyspnea
C. Fever
D. Hypotension
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? SATA
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
E. Occlusive dressing
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess respiratory status.
B. Apply sterile gauze to the insertion site.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? SATA
A. Gentle Constant bubbling in the suction control chamber
B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
C. Exposed sutures without dressing.
D. Drainage system upright at chest level
A. Gentle Constant bubbling in the suction control chamber
B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
A. Lie on it left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the valsalva maneuver
D. Perform the valsalva maneuver
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA
A. Encourage the client to cough every 2 hours
B. Check the continuous bubbling in th suction chamber
C. Strip the drainage tubing every 4 hours.
D. Clamp the tube once a day.
E. Obtain a chest x-ray
A. Encourage the client to cough every 2 hours
B. Check the continuous bubbling in th suction chamber
E. Obtain a chest x-ray
A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV?
A. “It keeps the alveoli open and prevents atelectasis.”
B. “It allows preset pressure delivered during spontaneous ventilation.”
C. “It guarantees minimal minute ventilator.
D. “It delivers a preset ventilatory rate and tidal volume to the client.”
B. “It allows preset pressure delivered during spontaneous ventilation.”
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevation blood pressure.
B. Pale skin
E. Elevation blood pressure.
A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings ever 8 hours.
C. Document tube placement in centimeters at the angle of jaw.
D. Assess breath sounds every 1 to 2 hours.
D. Assess breath sounds every 1 to 2 hours.
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
A. Non rebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask
B. Venturi mask
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the plan of care? SATA
A. Assist-control
B. SIMV
C. CPAP
D. PSV
E. Independent lung ventilation
B. SIMV
C. CPAP
D. PSV
A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? SATA
A. Client who has dysphagia
B. Client who has AIDS
C. Client who was vaccinated for pneumococcus and influenza 6 months ago
D. Client who is postoperative and received local anesthesia
E. Client who has a closed head injury and is receiving ventilation
F. Client who has Myasthenia Gravis
A. Client who has dysphagia
B. Client who has AIDS
E. Client who has a closed head injury and is receiving ventilation
F. Client who has Myasthenia Gravis
A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority?
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccine.
A. Obtain baseline vital signs and oxygen saturation.
A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions.
A. Administer antibiotics.
B. Administer oxygen therapy.
C. Perform a sputum culture.
D. Administer an antipyretic medication to promote client comfort.
B. Administer oxygen therapy.
C. Perform a sputum culture.
A. Administer antibiotics.
D. Administer an antipyretic medication to promote client comfort.
A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas
D. Palpation of the orbital areas
A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?
A. I should wash my hands after blowing my nose to prevent spreading the virus
B. “I need to avoid drinking fluids if I develop symptoms.”
C. “I need a flu shot every 2 years because of the different flu strains.”
D. “I should cover my mouth with my hand when I sneeze.”
A. I should wash my hands after blowing my nose to prevent spreading the virus
A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? SATA
A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVC’s)
B. Wheezing
C. Retraction of sternal muscles
E. Premature ventricular complexes (PVC’s)
A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?
A. Antibiotic
B. Beta-blocker
C Antiviral
D. Beta2 agonist
D. Beta2 agonist
A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching?
A. “I will decrease my fluid intake while taking this medication.”
B. “I will expected to have black, tarry stools.”
C. “I will take my medication with meals.”
D. “I will monitor for weight loss while on this medication.”
C. “I will take my medication with meals.”
A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?
A. Gender
B. Environmental allergies
C.Alcohol use
D. Race
B. Environmental allergies
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
A. “This medication can decrease my immune response.”
B. “I take this medication to prevent asthma attacks.”
C. “I need to take this medication with food.”
D. “This medication has a slow onset to treat my symptoms.”
B. “I take this medication to prevent asthma attacks.”
A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates and understanding of the teaching?
A. “This medication can increase my blood sugar levels.”
B. “This medication can decrease my immune response.”
C. “I can have an increase in my heart rate while taking this medication.”
D. “I can have mouth sores while taking this medication.”
C. “I can have an increase in my heart rate while taking this medication.”
A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication?SATA
A. Hypokalemia
B. Tachycardia
C. Fluid retention
D. Nausea
E. Black, tarry stools
A. Hypokalemia
C. Fluid retention
E. Black, tarry stools
A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?
A. “There are portable oxygen delivery systems that you can take with you.”
B. “When you go out, you can remove the oxygen and then reapply it when you get home.”
C. “You probably will not be able to go out at much as you used to.”
D. “Home health services will come to see you so you will not need to get out.”
A. “There are portable oxygen delivery systems that you can take with you.”
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will place the adapter on my finger to read my blood oxygen saturation level.”
B. “I will lie on my back with my knees bent.”
C. “I will rest my hand over my abdomen to create resistance.”
D. “I will take in a deep breath and hold it before exhaling.”
D. “I will take in a deep breath and hold it before exhaling.”
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care?
A. Take quick breaths upon inhalation.
B. Place you hand over your stomach.
C. Take a deep breath in through your nose.
D. Puff your cheeks upon exhalation.
C. Take a deep breath in through your nose.
A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? SATA
A. “I can substitute one medication for another if I run out because that all fight infection.”
B. I will wash my hands each time I cough
C. I will wear a mask when I am in a public area
D.”I am glad I don’t have to have any more sputum specimens.”
E. “I don’t need to worry where I go once I start taking my medications.”
B. I will wash my hands each time I cough
C. I will wear a mask when I am in a public area
.A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching?
A. “You will need to continue to take the multi-medication regimen for 4 months.”
B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication
C. “You will need to remain hospitalized for treatment.”
D. “You will need to wear a mask at all times.”
B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication
A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a
multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
A. “Your urine can turn a dark orange.”
B. “Watch for a change in the sclera of your eyes.”
C. “Watch for any changes in vision.”
D. “Take vitamin B6 daily.”
C. “Watch for any changes in vision.”
A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
A. “You might notice yellowing of your skin.”
B. “You might experience pain in your joints.”
C. “You might notice tingling of your hands.”
D. “You might experience loss of appetite.”
C. “You might notice tingling of your hands.”
A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
A. Persistent cough
B. Weight gain
C. Fatigue
D. Night sweats
E. Purulent sputum
A. Persistent cough
C. Fatigue
D. Night sweats
E. Purulent sputum
A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? SATA
A. A client who has a BMI of 30
B. A female client who is postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic a fib
A. A client who has a BMI of 30
C. A client who has a fractured femur
E. A client who has chronic a fib
A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? SATA
A. Bradypnea.
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
B. Pleural friction rub
D. Petechiae
E. Tachycardia
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?
A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.
C. Administer oxygen therapy.
A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse?
A. “I am allergic to morphine.”
B. “I take antacids several times a day.”
C. “I had a blood clot in my leg several years ago.”
D. “It hurts to take a deep breath.”
B. “I take antacids several times a day.”
A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy?
A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma
D. 1 week ago Elevated platelet count
A. Hip arthroplasty 2 weeks ago
A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? SATA
A. Tachypnea
B. Deviation of the trachea
C. Bradycardia
D. Decreased use of accessory muscles
E. Pleuritic pain
A. Tachypnea
B. Deviation of the trachea
E. Pleuritic pain
A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first?
A. Assess the client’s pain.
B. Obtain a large-bore IV needle for decompression.
C. Administer lorazepam.
D. Prepare for chest tube insertion.
B. Obtain a large-bore IV needle for decompression.
A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client?
A. “Notify the provider if you experience weakness.”
B. “You should be able to return to work in 1 week.”
C. “You need to wear a mask when in crowded areas.”
D. “Notify your provider if you experience a productive cough.”
D. “Notify your provider if you experience a productive cough.”
A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.)
A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first?
A. Obtain a chest ex-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via high-flow mask.
D. Initiate IV access.
C. Administer oxygen via high-flow mask.
A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
A. “This medication is given to treat infection.”
B. “This medication is given to facilitate ventilation.”
C. “This medication is given to decrease inflammation.”
D. “This medication is given to reduce anxiety.”
B. “This medication is given to facilitate ventilation.”
A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? SATA
A. A client who experienced a near-drowning incident
B. A client following coronary artery bypass graft surgery
C. A client who has a Hg 15.1
D. A client who has dysphagia
E. A client who experienced a drug overdose
A. A client who experienced a near-drowning incident
B. A client following coronary artery bypass graft surgery
D. A client who has dysphagia
E. A client who experienced a drug overdose
A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? SATA
A. Administer antibiotics.
B. Provide O2
C. Administer bronchodilators.
D. Administer antiviral meds
E. Maintain ventilatory support.
B. Provide O2
C. Administer bronchodilators.
E. Maintain ventilatory support.
A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome.
Which of the following medications should the nurse anticipate administering with this medication? SATA
A. Fentanyl
B. Furosemide
C. Midazolam
D. Famotidine
E> Dexamethasone
A. Fentanyl
C. Midazolam
A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching?
A. “Air should be instilled into the monitoring system prior to the procedure.”
B. “The client should be positioned on the left side during the procedure.”
C. “The transducer should be level with the second intercostal spaced after the line is placed.”
D. “A chest x-ray is needed to verify placement after the procedure.”
D. “A chest x-ray is needed to verify placement after the procedure.”
A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include?
A. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
B. Give cromolyn nebulizer solution every 6 hr (for asthma)
C. Apply a warm compress to the operative site every 4 hr
D. Administer analgesics on a scheduled basis for the first 24 hr
D. Administer analgesics on a scheduled basis for the first 24 hr
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take first?
A. Shave hairy areas of skin prior to application ( apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin)
B. Wear gloves to apply the patch to the client’s skin
C. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
D. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
pressed together)
B. Wear gloves to apply the patch to the client’s skin
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A. A client who is schedule for a procedure in 1 hr
B. A client who has 100 mL fluid remaining in his IV bag
C. A client who received a pain medication 30 min ago for postoperative pain
D. A client who was just given a glass of orange juice for a low blood glucose level
D. A client who was just given a glass of orange juice for a low blood glucose level
A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an increase in which of the following laboratory values?
A. Serum glucose level- increased
B. Serum Ca level decreased
C. Lymphocyte count decreased
D. Potassium decreased
A. Serum glucose level- increased
A nurse is caring for a client who has severe pre eclampsia and is receiving mg sulfate IV. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take?
A. Position the client supine
B. Prepare an IV bolus of destrose 5% in water
C. Administer methy lergonovine IM
D. Administer Ca gluconate IV
D. Administer Ca gluconate IV
A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?
A. Place the cap from the solution sterile side up on clean surfaces
B. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body’s first
C. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated.
D. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level
A. Place the cap from the solution sterile side up on clean surfaces
A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which action should the nurse take first?
A. Educate the client about medical Dx
B. Refer the client to a meal delivery program
C. Identify environmental hazards at home
D. Arrange a client for transportation
C. Identify environmental hazards at home
A nurse is assessing the remote memory of an older adult client who has mild dementia.
Which of the following questions should the nurse ask the client?
A. “Can you tell me who visited you today?”
B. What high school did you graduate from
C. Can you list your current medications?”
D. “What did you have for breakfast yesterday?”
B. What high school did you graduate from
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching
A. HbA1c level greater than 8%- 6.5 – 8 is the target reference.
B. Blood glucose level greater than 200 mg/dL at bedtime
C. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC
D. HbA1c level less than 7%
D. HbA1c level less than 7%
A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin . Which of the following should the nurse conclude if the client develops ataxia and incoordination?
A. The client is experiencing an adverse reaction to rifampin
B. Te client is showing evidence of phenytoin toxicity
C. The client’s seizure disorder is no longer under control
B. Te client is showing evidence of phenytoin toxicity
A nurse is caring for a client who is 1 hr post op following rhinoplasty. which of the following requires immediate action?
A. Increase frequency of swallowing
B. Moderate sanguineous drainage on the drip pad
C. Bruising to the face
D. Absent gag reflex
A. Increase frequency of swallowing
A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
A. Give scheduled doses of acetaminophen every 6 hr
B. Monitor the child cardiac status
C. Administer antibiotics via intermittent IV bolus for 24 hr
D. Provide stimulation with children of the same age in the playroom
B. Monitor the child cardiac status
A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
A. Use of tobacco might lead to alcohol and drug abuse
B. Smoking in adolescence increases the risk of developing lung cancer later in life
C. Use of tobacco decreases the level of athletic ability
C. Use of tobacco decreases the level of athletic ability
A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?
A. Total bilirubin
B. Urine ketones
C. Serum potassium
C. Serum potassium (diuretics that restrain K= hyperkalemia risk)
A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?
A. “I will let the client know that I am available as the interpreter.”
B. “I will receive a small fee for interpreting for this client.”
C. “I am glad I’m available today, but when I’m not, you can use a family member.”
A. “I will let the client know that I am available as the interpreter.”
A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider?
A. A two day old newborn who has a respiratory rate of 70
B. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool
C. A 2 day old newborn who has a small amount of blood tinged vaginal discharge
D. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 – 60 is normal
A. A two day old newborn who has a respiratory rate of 70 –> 30 – 60 is normal
A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first?
A. A client who has a elevated AST level following administration of azithromycin
B. A client who is 1 hr postoperative and has hypoactive bowel sounds
C. A client who has fractured left tibia and pallor in the affected extremity
D. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
C. A client who has fractured left tibia and pallor in the affected extremity
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider?
A. Weight gain
B. Dry mouth→ anticholinergic effects
C. sedation s/s neuroleptic malignant syndrome??>> life threatening
Sedation
D. Shuffling gait→A/E EPS: is an indication of parkinsonism and should be reported
D. Shuffling gait→A/E EPS: is an indication of parkinsonism and should be reported
A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching?
A. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge
baths
B. The cord stump will fall off in 5 days- about 10 – 14 days
C. Contact the provider if the cord stump turns black
D. Keep the cord stump dry until it falls
D. Keep the cord stump dry until it falls
A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client?
A. White flour tortillas
B. Potato pancakes
C. Wheat crackers
D. Canned barley soup
B. Potato pancakes
A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
A. All or nothing thinking
B. Euphoric mood
C. Disorganized speech
C. Disorganized speech
A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture?
A. Align a trochanter wedge between the clients legs
B. Place a towel roll under the clients neck
C. Apply an orthotic to the clients foot
C. Apply an orthotic to the clients foot
A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?
A. Provide anticipatory guidance classes to parents through public schools
B. Have a nurse from the outside the community provide health lectures at the county hospital
C. Encourage rural residents to focus health spending on tertiary health interventions
D. Launch a media campaign to increase awareness about industrial pollution
A. Provide anticipatory guidance classes to parents through public schools
A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?
A. Bellow the knee amputation→ESI Level 1
B. 10cm (4 in) laceration → ESI Level 4
C. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1.
D. 95% full thickness body burn →
A. Bellow the knee amputation→ESI Level 1
A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?
A. Hgb 12.8 g/dl – 12- 16
B. Potassium 4.2 meq/l 3.5 – 5.0 meq
C. RBC 4.4 million/mm3
D. Plateles 100,000 mm3
D. Plateles 100,000 mm3
A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?
A. Iron 90mcg
B. Prealbumin 10mcg
C. Cr 0.8mg/dl
B. Prealbumin 10mcg
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?
A. A client post op following a bowel resection with an NGT set to suction
B. A client who has fractured a femur yesterday and is expecting SOB
C. A client who sustained a concussion and has unequal pupils
D. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs
A. A client post op following a bowel resection with an NGT set to suction
A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . What should the nurse do?
A. Continue to monitor HR
B. Stop infusion
C. Perform vaginal examination
A. Continue to monitor HR
A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
A. Complete an incident report and place it in the client’s medical record
B. Compare the current infusion with the prescription in the client’s medication record.
C. Submit a written warning for the nurse involved in the incident.
B. Compare the current infusion with the prescription in the client’s medication record.
A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ?
A. WBC count 2,900 /mm3
B. FAsting blood glucose 100 mg/dl
C. Hgb 14 g/Dl
D. Heart rate 58/min
A. WBC count 2,900 /mm3
A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?
A. You may breastfeed unless your nipples are cracked or bleeding.
B. You must use a breast pump to provide breast milk.
C. You must use nipple shield when breastfeeding.
A. You may breastfeed unless your nipples are cracked or bleeding.
A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information?
A. Level of consciousness
B. Skin turgor
C. Bowel Sounds
A. Level of consciousness
A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ?
A. Submerge the adolescent feet in ice water
B. Cover the adolescent with a the
C. Initiate seizure precautions
C. Initiate seizure precautions
A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client’s airway, which of the following is the nurse’s priority intervention?
A. Providing pain management
B. Offering emotional support
C. Initiating IV fluid resuscitation
C. Initiating IV fluid resuscitation
A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA)
A.Hospice will take good care of your mom, so I wouldn’t worry about that.
B. Let’s talk about your mom’s cancer and how things will progress from here.
C. Tell me how you are feeling about your mom dying.
D. You sound like you have questions about your mom dying. Let’s talk about it.
B. Let’s talk about your mom’s cancer and how things will progress from here.
C. Tell me how you are feeling about your mom dying.
D. You sound like you have questions about your mom dying. Let’s talk about it.
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care?
A. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal)
B. A client who is scheduled for colonoscopy and taking sodium phosphate
C. A client who received a Mantoux test 48 hours ago and has induration
C. A client who received a Mantoux test 48 hours ago and has induration
A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?
A. Clarify the source of the referral
B. Implement the nursing process
C. Schedule a time for the home visit
D. Contact the family by phone
A. Clarify the source of the referral
A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response?
A. You have the right to decide who receives information
B. Your partner can be a great source of support for you at this time
C. Is there a reason you don’t want your partner to know about your procedure?
D. The provider will be tactful when talking to your partner
A. You have the right to decide who receives information
A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage?
A. 7.5%
B. 15%
C. 8.1%
D. 13.3%
A. 7.5%
A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement?
A.Perform fundal massage
B. Pour water from a squeeze bottle over the client’s perineal area.
C. Insert an indwelling urinary catheter.
B. Pour water from a squeeze bottle over the client’s perineal area.
A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?
A. Avoid hot tub while wearing the patch
B. Apply patch to your forearm
C. Avoid high-fiber foods while taking this medication
A. Avoid hot tub while wearing the patch
A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium.
A. Teach the client to shift his weight every 15 min while sitting
B. Place the client upright on a donut-shaped cushion
A. Teach the client to shift his weight every 15 min while sitting
A nurse is caring for a client who is experiencing mild anxiety . Which of the following findings should the nurse expect?
A. Heightened perceptual field
B. Rapid speech -severe
C. Feelings of dread
A. Heightened perceptual field
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic?SATA
A. Tremors
B. Diaphoresis
C. Acetone breath = DKA
D. Polydipsia= Hyperglycemia
E. Inability to concentrate
A. Tremors
B. Diaphoresis
E. Inability to concentrate
A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan?
A. Instruct healthcare professionals to identify abusive situations
B. Locate financial support to open a shelter for abuse survivors
C. Teach parenting skills to families at risk for abuse
C. Teach parenting skills to families at risk for abuse
A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP?
A. Documenting the report of pain for a client who is postoperative
B. Administering oral fluids to a client who has dysphagia
C. Applying a condom catheter for a client who has spinal cord injury
C. Applying a condom catheter for a client who has spinal cord injury
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
A. Offer the client saltine crackers between meals
Suggest rinsing his mouth with an alcohol-based mouthwash
Provide humidification of the room air
Instruct the client on the use of esophageal speech
A. Offer the client saltine crackers between meals
A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?
A. Assess effectiveness of antiemetic medication-
B. Perform chest compressions during cardiac resuscitation
C. Perform a dressing change for a new amputee-
D. Apply a transdermal nicotine patch-
B. Perform chest compressions during cardiac resuscitation
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?
A. The client takes vitamin C daily
B. The client has a history of alcohol use disorder
C. The client has a history of asthma
D. The client takes furosemide twice daily
C. The client has a history of asthma
A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects?
A. Increased salivation
B. Urinary retention
C. Weight loss
B. Urinary retention
A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?
A. Asthma
B. Hypertension
C. Fibromyalgia
D. Fibrocystic breast condition
B. Hypertension
A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA)
A. Explain the procedure
B. Expected outcome of the procedure
C. Potential complications
D. Possible alternative treatments
E. Cost of the procedure
A. Explain the procedure
B. Expected outcome of the procedure
C. Potential complications
D. Possible alternative treatments
A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching?
A. You should not have this procedure if you are allergic to iodine.”
B. You should not have this procedure if you have a tattoo.”
C. “The nurse will ask you to wear protective eyewear during this procedure.”
D. “The nurse will ask you to remove any transdermal patches prior to the procedure.”
A. You should not have this procedure if you are allergic to iodine.”
A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care?
A. Initiate IV fluid replacement
B. Start a 24 hour urine collection
C. Give aspirin
D. encourage ambulation
A. Initiate IV fluid replacement
A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take?
A. Summon a security guard
B. Explain the risks of leaving
C. Complete an incident report
B. Explain the risks of leaving
A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?
A. “I try to respond to the baby quickly .”
B. I think the baby should be sleeping through the night by now
C. “I have several friends who come by to help out with the baby.”
B. I think the baby should be sleeping through the night by now
A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider?
A. Temperature 38 C(100.4 F) and pulse rate 124/min p
B. Decreased appetite and irritability
C. Pale and 24-hour fluid deficit of 30 mL
D. Sunken fontanels and dry mucous membranes
D. Sunken fontanels and dry mucous membranes
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information?
A. Request a female translator
B. Ask a student nurse who speaks the same language to translate
C. Have the child translate
D. Allow the clients partner to translate
A. Request a female translator
A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ?
A. Folate levelB.
B. INR level
C. Vitamin b12 level
D. Creatinine level
C. Vitamin b12 level
A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP?
A. Suction a new tracheostomy
B. Remove an NG tube
C. Perform post mortem care
D. Change the dressing on an implanted central venous access device
C. Perform post mortem care
A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored?
A. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls
B. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus)
C. Uterine atony( fundus not firm which means possible hemorrhage)
D. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly)
A. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls
A nurse is caring for a client who has acute glomerulonephritis. Which of the following should the nurse expect ?
A. Polyuria- oliguria
B. Hypotension- hypertension
C. Hematuria
D. Weight loss – weight gain
C. Hematuria
A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?
A. your baby will be given 2 ounces of water to drink prior to the test
B. this test will be repeated when your baby is 2 months old
C. a nurse will draw blood from your baby’s inner elbow
D. this test should be performed after you baby is 24 hours old
D. this test should be performed after you baby is 24 hours old
A nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?
A. placing a yellow bracelet on a client who is at risk for falls
B. administering potassium via IV bolus
C. documenting communication with a provider in the progress notes of the client’s medical record
D. leaving a nasogastric tube clamped after administering oral medication
B. administering potassium via IV bolus
A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness.
Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. (cheeks area)
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
A. Take pancrelipase
B. Complete oral hygiene
C. Eat a meal
D. Use an albuterol inhaler
D. Use an albuterol inhaler
A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take?
A. Offer high-calorie, high protein snacks to the client
B. Recommend the family provide the client privacy during meals
C. Weigh the client once each day
D. Encourage the client to eat foods selected by the dietitian
A. Offer high-calorie, high protein snacks to the client
A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client’s decision to wear his own clothing ?
A. Non maleficence
B. Veracity
C. Autonomy
D. Justice
C. Autonomy
A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ?
A. Check the mouth for smooth and smoky breath – airway obstruction via foreign body
B. Calculate the fluid replacement based on vital signs and urinary output
C. Determine the location and depth of burns
D. Administer antibiotics to prevent sepsis.
A. Check the mouth for smooth and smoky breath – airway obstruction via foreign body
A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ?
A. Hyponatremia
B. Hyperkalemia
C. Hypercalcemia
D. hypoglycemia
A. Hyponatremia
A nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks?
140 lbs or 63.6 kg (64 kg)
A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
A. I will change my baby’s diaper at least every 4 hours
B. I will apply an ice pack to my baby’s penis twice daily to decrease swelling
c. I will wash the penis with soap and warm water until the circumcision has healedd.
D. I will apply topical lidocaine following each diaper change Teach the parents to keep
the area clean.
A. I will change my baby’s diaper at least every 4 hours
A home health nurse is caring for an adult client who reports, “I keep coughing when I try to
swallow my food, but not at other times.” Which of the following actions should the nurse take?
A. encourage the client to increase fluid intake
B. initiate a consultation with a speech
C. instruct the client that this is due to increased salivary flow that occurs with aging
D. recommend an antitussive 30 minutes prior to each meal
B. initiate a consultation with a speech
A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control?
A. Postprandial blood glucose 190 mg/dl
B. Fasting blood glucose 60 mg/dl
C. HbA1c 6.5%
D. Hct 42%
C. HbA1c 6.5%
A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication?
A. BUN
B. Blood pressure
C. Respiratory rate
D. aPTT
B. Blood pressure
A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention?
A. Encouraging the client to use jet therapy on her lower back for 1 hr
B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen
C. Using effleurage on a client’s lower abdomen
D. Instructing a client’s partner how to apply counter pressure to the client’s sacral spine for 30
min
B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen
A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of step s the nurse should follow when delegating tasks to the APs.
A. Monitor progress of task completion with each AP
B. Review the skill level of and qualifications of each AP
C. Communicate appropriate tasks to the APs with specific expectations
D. Evaluate the APs’ performance of each task
B. Review the skill level of and qualifications of each AP
C. Communicate appropriate tasks to the APs with specific expectations 2
A. Monitor progress of task completion with each AP 3
D. Evaluate the APs’ performance of each task 4
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
A. “I should take antibiotics when I have a virus.”
B. “I should wash my hands for 10 seconds with hot water after working in the garden.”
C. “I can clean my cat’s litter box during my pregnancy.”
D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted
D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted
A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following
actions should the nurse take?
A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
C. Apply continuous pressure 2.5 cm (1 in above the percutaneous skin site.
D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
C. Apply continuous pressure 2.5 cm (1 in above the percutaneous skin site.
A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure?
A. Sensation of skin warmth
B. Headache
C. Increased salivation
D. Numbness and tingling of the extremities
A. Sensation of skin warmth
A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?
A. Lorazepam .5 mg PO one tablet daily
B. Hydrochlorothiazide 12.5 mg PO BID
C. Triamcinolone acetonide 100 mcg/inhalation
D. Zolpidem 10 mg PO one tablet at bedtime
A. Lorazepam .5 mg PO one tablet daily
A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority?
A. Excoriation of the skin on the neck and chest
B. Dysphagia
C. Client reports a pain level of 6 on scale from 0-10
D. Xerostomia
B. Dysphagia
A nurse is assessing a client who is 2 hrs postpartum for uterine atony . Which of the following action should the nurse take?
A. Monitor the client’s urinary output
B. Check the client VS
C. Evaluate the client’s pain level
D. Palpate the client’s fundus
D. Palpate the client’s fundus
A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client?
A. Disinfect and powder any latex products before use
B. Tape stockinet over monitoring device and cords
C. Schedule the client as the last surgery of the day
D. Remove poopsocks from the IV
B. Tape stockinet over monitoring device and cords
A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication.
A Dumping syndrome
B Ketoacidosis
C Hepatotoxicity
D Thyroid storm
A Dumping syndrome
A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA)
A. Place the client in a semi-private room
B. Wear a lead apron when providing care
C. Limit visitors to 30 mins
D. Instruct visitors who are pregnant to remain 3 ft from the client
E. Close the door to the client’s room
B. Wear a lead apron when providing care
C. Limit visitors to 30 mins
A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching?
A. Client can expect to have feeling of hopelessness
B. Client might feel guilt over some aspect of their loss
C. Client will experience anhedonia
D. Client will experience low self-esteem
B. Client might feel guilt over some aspect of their loss
A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate?
A. Offer your son a gift when the baby receives one
B. Move your son to a toddler bed when the baby arrives
C. Tell your son to kiss the baby
D. Teach your son to change the baby diapers
A. Offer your son a gift when the baby receives one
A nurse is assessing a newborn who has patent ductus arteriosus . Which of the following findings should the nurse except?
A. Increase PaO2
B. Hypoglycemia
C. Board-like abdomen
D. Bounding pulse
D. Bounding pulse
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?
a. Measure the client’s urine output every hour.
b. Restrict the client’s total fluid intake to 250ml/hr.
c. Monitor the FHR via Doppler every 30 min
d. Give the client protamine if sign of magnesium sulfate toxicity occur.
a. Measure the client’s urine output every hour. – monitor for toxicity.
A nurse is caring for a client who has end stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?
a. Hypertension
b. Primary glaucoma
c. Osteoarthritis
d. Amputation
a. Hypertension
A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take?
a. Administer a bronchodilator following meals.
b. Request non gas forming foods from the dietary department
c. Limit the client’s food consumption between meals.
d. Arrange for a low protein diet. HIGH PROTEIN.
b. Request non gas forming foods from the dietary department
A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department?
a. Candidiasis
b. Herpes simplex virus
c. Human papillomavirus
d. Chlamydia
d. Chlamydia
A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take?
a. Place a cardiac monitor on the client
b. Stop the IV infusion of insulin
c. Administer oral potassium to the client- potassium is already high
d. Initiate a 24 hr urine collection
a. Place a cardiac monitor on the client
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
a. I can go jogging after 2 weeks. -Avoid vigorous activities.
b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds.
c. I can resume activities, such as sewing.
d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level.
c. I can resume activities, such as sewing.
- A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?
a. Give the dose over 60 min
b. Administer the medication undiluted
c. Obtain trough level 30 min after the medication infusion
d. Inject 1% lidocaine prior to each dose
a. Give the dose over 60 min
A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make?
a. Take the client in room 106 to radiology
b. Take the vital signs of the clients on the side of the unit
c. Tell me the standing weight of the client in room 102 before breakfast
d. The client in room 109 has spilled his water pitcher Rationale: right direction/communication. Leadership.
c. Tell me the standing weight of the client in room 102 before breakfast
. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority?
a. Erythema 5 cm (2in) above the IV site
b. Blood pressure 92/68 mm Hg –
c. Urine output 35mL/hr
d. Pedal pulse of +1 bilaterally
a. Erythema 5 cm (2in) above the IV site
A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?
A. Positioning both hands on the grips with his elbows slightly flexed
B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight)
C. Stepping with his affected leg first when going up stairs (Unaffected First)
D. Moving both crutches with the stronger leg forward
A. Positioning both hands on the grips with his elbows slightly flexed
A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform?
A. Hop on one foot
B. Kick a ball forward
C. Climb Stairs with alternate feet
D. Ride a tricycle
B. Kick a ball forward
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
A. Im sure you can find alternative remedies through an online support group
B. If there are therapies available to you, your provider will tell you about them
C. Feel free to try whatever therapies that fit within your personal belief system
D. We can review some information to help you select a safe alternative practitioner.
D. We can review some information to help you select a safe alternative practitioner.
A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?
A. The client reports a metallic taste in his mouth
B. A client reports a decreased appetite
C. The client coughs after swallowing
D. The client has poor fitting dentures
C. The client coughs after swallowing
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure?
A. Compare the client’s current weight with preprocedure weight.
B. Check the client’s serum albumin levels
C. Examine for leakage at thes site of the procedure
D. Confirm that the client is able to urinate
A. Compare the client’s current weight with preprocedure weight.
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
A. Swaddle the newborn with this leg extended.
B. Maintain eye contact with the newborn during feedings.
C. Minimize noise in the newborn environment
D. Administer naloxone to the newborn
C. Minimize noise in the newborn environment
● Reduce environmental stimuli (decrease lights, lower noise level).
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness?
A. Participate in community drills and mock events.
B. Vaccinate susceptible children and adults against smallpox
C. Assess types, levels and scopes of disasters.
D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First
A. Participate in community drills and mock events.
A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution?
A. Severe renal impairment. (Stage IV Kidney Disease)
B. Chronic alcohol use disorder
C. Multiple sclerosis
D. Advanced cardiac disease.
A. Severe renal impairment. (Stage IV Kidney Disease)
A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings?
a. Fourth heart sound at the aortic area
b. Murmur at the mitral area
c. Third heart sound at the tricuspid area
d. Pericardial friction rub at the pulmonic area
b. Murmur at the mitral area
A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching?
a. I will remove dairy products from my diet
b. I will remove peanuts from my diet
c. I will remove bananas from my diet
d. I will remove gluten from my diet
c. I will remove bananas from my diet
****People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato
A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?
a. Seizure disorder
b. Polycystic ovary syndrome
c. Renal insufficiency
d. Gluten intolerance
c. Renal insufficiency
A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first?
a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site
b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120
c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate
d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing
d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing – bleeding
A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching?
a. I will alternately contract and relax my gluteal muscles
b. I will perform the exercises once each day before bed
c. I will try to hold my urine for a little after i first feel the urge to urinate
d. I will determine which muscles to contract by stopping and starting my stream of urine
d. I will determine which muscles to contract by stopping and starting my stream of urine
A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching?
a. I need to have an enema before the test
b. I should urinate before the test
c. I will lie on my left side during the test
d. I will drink an oral glucose solution during the test
a. I need to have an enema before the test
A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?
a. Memory loss
b. Slurred speech
c. Elevated temperature
d. hypotension
c. Elevated temperature
***● Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension
A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client?
a. Report of occipital headache
b. Scratchy, high pitched sound upon chest auscultation
c. ECG demonstrates a depressed ST segment
d. White, diffuse peritonsillar pustules
b. Scratchy, high pitched sound upon chest auscultation
.A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse?
a. Inform the transferring agency of the client’s condition.
b. Privately interview the client about her condition.
c. Notify risk management
d. Contact the family regarding the client’s condition.
b. Privately interview the client about her condition.
A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will decrease my protein intake during the third trimester”( increase protein for basic growth)
b. “I will need to increase my insulin doses later in my pregnancy”
c. “I will increase my carbs at breakfast and limit them the rest of the day”
d. “I will decrease my calorie consumption during the first trimester”(increase calorie)
b. “I will need to increase my insulin doses later in my pregnancy”
A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first?
a. Test the client for Trousseau’s sign
b. Assess the client’s skin turgor
c. Check the client’s motor strength
d. Measure the client’s pupil size
a. Test the client for Trousseau’s sign
A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching?
a. “I should clean my stoma with warm water”( can use low ph soap and water)
b. ” My stoma should be bright pink or red”(pink,red and moist)
c. “I should change the stoma pouch every day”
d. “I should cut my pouch opening ⅛ inch larger than my stoma”(allow expansion)
c. “I should change the stoma pouch every day
Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full.
A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity?
a. Hyporeflexia
b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction)
d. Polyuria (oliguria, less than 30 ml/hr)
a. Hyporeflexia
.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero
Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736
.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
a. Administer enalapril 2.5 mg PO twice daily
b. Ambulate the client every 4 hr while awake(bedrest)
c. Provide the client with 4 g sodium diet(
d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr
a. Administer enalapril 2.5 mg PO twice daily
A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA)
b. Clamp the catheter distal to the injection port
c. Collect 2 mL of urine for each specimen
d. Obtain the urinalysis specimen before the culture specimen
b. Clamp the catheter distal to the injection port
A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations?
A. Orthostatic Hypertension
B. Dependent Edema
C. Decreased Hematocrit
D. Neck Vein Distension
A. Orthostatic Hypertension
. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
A. 3+ deep tendon reflexes
B. Protruding Hemorrhoids
C. Urinary Frequency (expected)
D. Supine Hypotension
B. Protruding Hemorrhoids
rational for option A
(common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.)
A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first?
A. Inform the provider of the time of the last dose of pain medication.
B. Document the sequence of events as they occur.
C. Provide non-pharmacological pain management interventions.
D. Instruct the client about the steps of the procedure
A. Inform the provider of the time of the last dose of pain medication.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
A. The client was intubated without complications.
B. The estimated blood loss was 250 milliliters.
C. There was a total of 10 sponges used during the procedures.
D. The client is a member of the board of directors.
B. The estimated blood loss was 250 milliliters.
A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?
A. Left ventricular failure
B. Cardiogenic shock
C. Hypovolemia
D. Hypotension
A. Left ventricular failure
A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?
A. Fasting blood glucose 108 mg/dl (WNL)
B. WBC 9,800/mm (WNL)
C. Creatinine 0.9 mg/dl (WNL)
D. Potassium 5.2 mEq/L
D. Potassium 5.2 mEq/L
A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?
A. Engage the client in activities that increase sensory stimulation.
B. Discourage physical activity during the day.
C. Establish a toileting schedule for the client.
D. Use clothing with buttons and zippers.
C. Establish a toileting schedule for the client.
A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations
a. Orthostatic hypotension –
b. Dependant Edema- fluid volume excess
c. Decreased Hematocrit – fluid volume excess d/t super diltion
d. Neck vein distention – fluid volume excess
a. Orthostatic hypotension
A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation?
a. Identify Solutions prior to negotiation
b. personalize the conflict
c. Attempt to understand both sides of the issue
d. Focus on how the conflict occurred
c. Attempt to understand both sides of the issue
Assess the situation first prior to trying to solve it
A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take?
a. Insert a new IV catheter distal to the discontinued IV site
b. apply pressure dressing at the IV site
c. Please a warm moist compress on the site
d. Express drainage from the IV site and send it to be cultured
c. Please a warm moist compress on the site
Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area.
A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?
a. ADD medication directly to enteral feeding – not without crushing them first
b. Dissolve the medications together- some medications can mix others can’t
c. Use a syringe to allow the medications to Flow by gravity
d. Flush the NG tube with 5 ml water- 10ml
c. Use a syringe to allow the medications to Flow by gravity
The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
a. Repeated acts of unlawful Behavior
b. Suspicious demeanor
c. Seductive Behavior
d. Lack of remorse
c. Seductive Behavior
A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching?
a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor
b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby
c. The nurse will initiate acupuncture when I arrive at the unit – Needles during labor no.
d. I can use my ultrasound picture as a focal point during contractions
d. I can use my ultrasound picture as a focal point during contractions
A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider?
a. Heart rate 98 per minute
b. ST segment elevations_ Remember this could possibly lead to infarctions
c. 2 PVCs per minute
d. Widened P wave
b. ST segment elevations_ Remember this could possibly lead to infarctions
A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene ?
a. Plans for a check of the clients fingerstick glucose every 6 hours
b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok
c. Uses the tpn IV tubing to administer the clients next dose of antibiotic
d. Increases the tpn infusion rate each hour until the prescribed rate is achieved
c. Uses the tpn IV tubing to administer the clients next dose of antibiotic
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching?
a. Yield in situations of conflict to maintain group Harmony – If conflict arises it is your responsibility to contain it
b. Share personal opinions to help influence the group’s values -your focus is having group share their personal thoughts and feelings to facilitate discussion
c. Use modeling to help the clients improve their interpersonal skills
d. Measure the accomplishments of the group against a previous group – no comparison
c. Use modeling to help the clients improve their interpersonal skills
A nurse is assessing a client’s respirations which of the following actions should the nurse take?
a. Assess respirations before counting radial pulsations -either or is fine
b. Multiply the number of respirations in 15 seconds by 4 – short way to do it, not necessarily the right way
c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear
d. Count respirations for 1 minute if the rhythm is irregular
d. Count respirations for 1 minute if the rhythm is irregular
A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take?
a. Report the information to the charge nurse
b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff
c. contact the laboratory manager regarding the situation – you are not high enough up the chain to do that
d. Notify the facilities legal department – no need to go that far
a. Report the information to the charge nurse
A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive?
a. Concurrent use of levothyroxine
b. Allergy to penicillin
c. Recurrent urinary tract infections
d. Migraines with aura
d. Migraines with aura
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8
b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%
c. A client who is at 28 weeks of gestation and reports leukorrhea
d. A client who has preeclampsia and reports a persistent headache
d. A client who has preeclampsia and reports a persistent headache
A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?
a. Instruct the client to empty her bladder prior to the procedure.
b. Position the client over an overbed table prior to the procedure.
c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure.
d. Initiate NPO status 4 hr prior to the procedure.
a. Instruct the client to empty her bladder prior to the procedure.
A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor?
a. Arterial blood gas
b. Serum potassium
c. Liver function test
d. Serum creatinine
c. Liver function test
A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?
a. Discard the first 10 mL of urine.
b. Apply EMLA cream prior to the procedure.
c. Obtain a 12 French catheter.
d. Don sterile gloves prior to the procedure
d. Don sterile gloves prior to the procedure
. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider?
a. Potassium 3.2 mEq/L 3.5 – 5.0 is normal
b. BUN 16 mg/dL (Normal 10-20)
c. PT 12.2 seconds (Normal 11-14)
d. Fasting blood glucose 103 mg/dL
a. Potassium 3.2 mEq/L 3.5 – 5.0 is normal
A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?
a. “How long have you been hearing the voices?”
b. “What are the voices telling you?”
c. “Have you taken your medication today?”
d. “I realize the voices are real to you, but I don’t hear anything.”
b. “What are the voices telling you?”
A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the following findings as an indication of a possible allergic reaction to the medication?
A. Bradycardia
B. Headache
C. Joint pain
D. Hypotension
D. Hypotension
A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing auditory hallucinations telling them to hurt others. The client is refusing to take anti-psychotic medication. Which of the following responses should the nurse make?
A. “You should plan to take this medication for a few weeks.”
B. “You will regret it if you do not take this medication.”
C. “This medication will help you respond to the voices.
D. “This medication will help you stop the voices you are hearing.”
D. “This medication will help you stop the voices you are hearing.”
A nurse is providing care for a patient who has depression and is to have electroconvulsive therapy. Which of the following conditions should the nurse identify as increasing the client’s risk for complications?
A. Hyperthyroidism
B. Renal calculi
C. Diabetes mellitus
D. Cardiac dysrhythmias
D. Cardiac dysrhythmias
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider?
A. WBC count 8,000/mm
B. Platelets 150,000/mm
C. Aspartate aminotransferase 10 units/L
D. Erythrocyte sedimentation 75 mm/h
D. Erythrocyte sedimentation 75 mm/hr
A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that suctioning has been effective?
A. Presence of a productive cough
B. Decreased peak inspiratory pressure
C. Thinning of mucous secretions
D. Flattening of the artificial airway cuff
A. Presence of a productive cough
. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
A. Stand within 30cm (1 ft) of the client when speaking with them.
B. Express sympathy for the client’s situation.
C. Confront the client about his behavior.
D. Speak assertively to the client.
D. Speak assertively to the client.
A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing’s disease. Which of the following actions is the nurse’s priority?
A. Reposition the client for comfort every 2 hours
B. Observe for any indications of infection
C. Document amount and color of the incisional drainage.
D. Monitor the client’s fluid and electrolyte status.
D. Monitor the client’s fluid and electrolyte status.
A nurse is caring for a client who is scheduled for a surgical procedure and states, “I don’t want to have this surgery anymore.” Which of the following responses should the nurse make?
A. “We can manage your care following the procedure without complications.”
B. “You have the right to refuse the procedure.”
C. “Your doctor thinks the surgery is necessary.”
D. “Let me review the procedure so you can understand what is going to happen.”
B. “You have the right to refuse the procedure.”
A nurse is evaluating a client who has borderline personality disorder. Which of the following behaviors indicates an improvement in the client’s condition?
A. Impulsive behaviors
B. Decreased clinging behavior
C. Liability of mood
D. Dependent behavior
B. Decreased clinging behavior
A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
A. Air-popped popcorn
B. Milkshake made with whole milk.
C. Baked potato chips
D. Cheesecake
A. Air-popped popcorn
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium
B. Ibuprofen
C. Acetaminophen
D. Aspirin
C. Acetaminophen
A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse plan to administer?
A. Colchicine
B. Lorazepam
C. Pregabalin
D. Codeine
C. Pregabalin
A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. Which of the following laboratory values indicates that the client is at risk for developing digoxin toxicity?
A. Glucose 150 mg/dL
B. Magnesium 1.3 mEq/L
C. Potassium 3.1 mEq/L
D. Sodium 134 mEq/L
C. Potassium 3.1 mEq/L
A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of the following in the client’s history should the nurse identify as a contraindication for receiving alteplase?
A. Hip arthroplasty 1 week ago correct
B. Obstructive lungs disease
C. Retinal detachment
D. Acute kidney failure 6 months ago
A. Hip arthroplasty 1 week ago correct
A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?
A. “I will soak in the tub rather than showering.”
B. “I can hold my cellphone on the same side of my body as the ICD.”
C. “I will wear loose clothing over my ICD.”
D. “I will avoid using my microwave oven at home because of my ICD.”
C. “I will wear loose clothing over my ICD.”
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions should the nurse anticipate?
A. Clamp the catheter tubing for 30 min
B. Initiate continuous bladder irrigation
C. Obtain a urine specimen for culture and sensitivity
D. Administer a fluid bolus
C. Obtain a urine specimen for culture and sensitivity
A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?
A. Avoid talking to the client about the newborn
B. Discourage the client from allowing friends to see the newborn C. Offer to take pictures of the newborn for the client
D. Assure the client that she can have additional children
C. Offer to take pictures of the newborn for the client
A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse’s priority to prevent wound infection?
A. Use sterile dressings for wound care
B. Apply topical antibiotics to the client’s wounds.
C. Place the client in protective isolation.
D. Maintain consistent hand washing by staff.
D. Maintain consistent hand washing by staff.
A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states, “Providing constant care is very stressful and is affecting all areas of my life.” Which of the following actions should the nurse take?
A. Discuss methods of how to communicate with the client about problem solving behaviors.
B. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
C. Assist the caregiver to arrange a daycare program for the client.
D. Recommend allowing the client to have time alone in their room throughout the day.
C. Assist the caregiver to arrange a daycare program for the client.
A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?
A. Administer a benzodiazepine
B. Perform a fundal massage
C. Place an ice pack on the client’s perineum
D. Place the client’s hand in warm water
D. Place the client’s hand in warm water
A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
A. Compare a list of common medications to treat a condition to the actual prescriptions
B. Compare the prescription to the allergy history of the client
C. Compare the medication label to the provider’s prescription on three occasions before administration
D. Compare the client’s list of home medications to the admission prescriptions written for the client
D. Compare the client’s list of home medications to the admission prescriptions written for the client
A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has preterm labor. Which of the following findings should the nurse identify as an adverse effect of this medication?
A. Hyperglycemia
B. Uterine contractions
C. Proteinuria
D. Hypotension
A. Hyperglycemia
A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (SATA)
A. Apply a tourniquet above the catheter insertion site.
B. Access the catheter using a large bore needle.
C. Aspirate for blood return to access catheter patency.
D. Flush the catheter with 0.9% sodium chloride.
E. Apply force when resistance is met while flushing the catheter.
A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?
A. Explain in simple terms how the procedure will affect the child.
B. Ask the parents to wait outside the room during the procedure. C. Limit teaching sessions about the procedure to 20 min.
D. Instruct the child in deep-breathing methods prior to the procedure.
A. Explain in simple terms how the procedure will affect the child.
A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?
A. Irrigate the wound using a 10-mL syringe.
B. Cleanse the wound starting at the bottom and moving upward.
C. Cleanse the insertion site of the drain using a circular motion towards the center.
D. Irrigate the wound with a low-pressure flow of solution.
D. Irrigate the wound with a low-pressure flow of solution.
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A. A client who is at 36 weeks of gestation and has a biophysical profile score of 8.
B. A client who has preeclampsia and reports a persistent headache.
C. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%.
D. A client who is at 28 weeks of gestation and reports leukorrhea.
B. A client who has preeclampsia and reports a persistent headache.
A nurse is caring for a client who is recovering from an amputation of her right arm above the elbow. Which of the following information should the nurse report the occupational therapist?
A. The client’s parent is in a skilled nursing facility.
B. The client has two small children at home.
C. The client is allergic to penicillin.
D. The client lives in a two-story home.
B. The client has two small children at home.
A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone.” Which of the following responses should the nurse make? A. “You should join a community support group.”
B. “What makes you think that?”
C. “Don’t worry. You should be feeling better in a couple weeks.”
D. “Can you give me an example of how others are making you feel this way?”
D. “Can you give me an example of how others are making you feel this way?”
A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?
A. Prepare for a CT scan.
B. Insert a peripheral IV line.
C. Establish a patent airway.
D. Apply direct pressure to the nose
C. Establish a patent airway.
. A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
A. Confabulation
B. Agnosia
C. Projection
D. Perseveration
A. Confabulation
A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?
A. Place a handrail in the entryway of the house.
B. Place a towel on the floor outside of the shower.
C. Ensure that all area rugs are rubber-backed.
D. Wear slippers with cloth soles
A. Place a handrail in the entryway of the house.
A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
A. Raise the head of the client’s bed to a high-fowler’s position.
B. Elevate the client’s effected leg on a pillow when in bed.
C. Position the client’s knees slightly higher than the hips when up in a chair.
D. Keep an abduction pillow between the client’s legs.
D. Keep an abduction pillow between the client’s legs.
A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster virus. Which of the following information should the nurse include?
A. Children who have varicella should be placed on droplet precautions.
B. Children who have varicella are contagious 4 days before the first vesicle eruption.
C. Children who have varicella are contagious until the vesicles are crusted.
D. Children who have varicella should receive the herpes zoster vaccine.
C. Children who have varicella are contagious until the vesicles are crusted.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Teach the client how to meditate
B. Sit with the client to provide a sense of security.
C. Encourage the client to watch television.
D. Administer a dose of atomoxetine to decrease anxiety
B. Sit with the client to provide a sense of security.
A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?
A. Stands with feet together when lifting a client up in bed.
B. Places a gait belt around the client’s upper chest before assisting a client to stand.
C. Uses a mechanical lift device to move a client from the bed to the chair.
D. Raises the client’s head of the bed before pulling the client up
C. Uses a mechanical lift device to move a client from the bed to the chair.
A nurse is teaching a client about condom use. Which of the following client statements should the nurse identify as an understanding of the teaching?
A. “I can use petroleum jelly as a lubricant with the condom.”
B. “I can re-use the condom one time after initial use.”
C. “I can use natural-skin condoms to prevent sexually transmitted infections.”
D. “I can store the condoms in the drawer of my night-stand.”
D. “I can store the condoms in the drawer of my night-stand.”
A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (SATA)
A. Maintain the collection chamber above the level of the client’s waist.
B. Mark the drainage output on the collection chamber hourly.
C. Clamp the chest tube every 2 hours to assess the amount of drainage.
D. Add water to the water seal chamber as it evaporates. E. Strip the chest tube vigorously to dislodge blood clots.
B. Mark the drainage output on the collection chamber hourly.
D. Add water to the water seal chamber as it evaporates.
The nurse is reviewing a medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication to heat therapy?
A. Osteoarthritis
B. Peripheral neuropathy
C. Abdominal aortic aneurysm
D. Phlebiti
B. Peripheral neuropathy
A charge nurse is recommending postpartum clients for discharge following a local disaster. Which of the following client’s should the nurse recommend for discharge first?
A. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
B. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
C. A client who delivered precipitously and has a second-degree perineal laceration
D. A client who has received 2 units of RBCs 6 hr ago for a postpartum hemorrhage
C. A client who delivered precipitously and has a second-degree perineal laceration
A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching?
A. The client flexes her elbows 10 degrees when supporting weight by using the handgrips. ATI page 222 Fundy. IT HAS TO BE 30 DEGREE
B. The client places the crutches 30 cm (12 in) to the front and side of each foot while standing
C. The client leans on both crutches to support body weight.
D. The client keeps her axillae free of pressure.
D. The client keeps her axillae free of pressure.
A nurse is preparing the body of a client who has died for the family to view. Which of the following actions should the nurse take?
A. Place a pillow under the client’s head.
B. Remove the client’s dentures.
C. Remove the client’s identification tags.
D. Place the client’s arms across their chest.
A. Place a pillow under the client’s head.
A nurse is reviewing annual education requirements for fire safety. Identify the sequence that the nurse should use when operating a fire extinguisher.
- Unlock the handle by pulling on the pin.
- Point the hose at the base of the fire.
- Squeeze the handles together.
- Sweep the extinguisher from side to side.
- Unlock the handle by pulling on the pin.
- Point the hose at the base of the fire.
- Squeeze the handles together.
- Sweep the extinguisher from side to side.
A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make?
A. Ensure that the client has a living will on file prior to treatment.
B. Place copies of incident reports in the clients’ medical records.
C. Obtain personal professional liability insurance coverage.
D. Overestimate the clients’ acuity to prevent short staffing.
A. Ensure that the client has a living will on file prior to treatment.
A nurse is caring for a client who speaks a language different than the nurse. Which of the following actions should the nurse make?
A. Review the facility policy about the use of an interpreter.
B. Direct attention toward the interpreter when speaking to the client.
C. Request a family member or friend to interpret information to the client.
D. Request an interpreter of a different sex from the client.
A. Review the facility policy about the use of an interpreter.
A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following findings should the nurse identify as a manifestation of hypovolemic shock? A. Decreased respiratory rate
B. Change in level of consciousness
C. Increased urine output
D. Hyperactive deep-tendon reflexes
B. Change in level of consciousness
A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
A. Position the casted extremity on a pillow.
B. Place an ice pack over the cast.
C. Teach the client to keep the cast clean and dry.
D. Palpate the pulse distal to the cast
D. Palpate the pulse distal to the cast
A nurse is performing a gait assessment on a client to evaluate the client’s ability to perform ADLs. Which of the following findings indicates a standard gait?
A. The client looks at the floor when walking.
B. The client’s shoulders are rounded slightly forward.
C. The client’s heels touch the ground before their toes.
D. The client’s dominant foot bears more weight.
C. The client’s heels touch the ground before their toes.
A nurse on a mental health unit is caring for a client who has suicidal ideation. Which of the following actions should the nurse take?
A. Place the client in a group therapy session.
B. Avoid discussing suicidal thoughts with the client.
C. Give the client a radio to listen to in his room.
D. Establish a no-suicide contract with the client.
D. Establish a no-suicide contract with the client.
A nurse is providing teaching about nutrition therapy to a client who is experiencing anorexia due to chemotherapy treatment. Which of the following statements should the nurse make?
A. “Snack frequently on fresh fruit.”
B. “Add water to soups to increase volume.”
C. “Avoid adding butter to foods.”
D. “Add grated cheese to vegetable dishes.”
D. “Add grated cheese to vegetable dishes.”
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about administering NPH and regular insulin together in one injection. Which of the following instructions should the nurse include?
A. Inject into the vastus lateralis.
B. Draw up the regular insulin prior to NPH.
C. Use a 15-degree angle for the injection.
D. Roll the syringe gently to ensure mixture of the insulins
B. Draw up the regular insulin prior to NPH.
A nurse is caring for a client who has a calcium level of 8 mg/dL. Which of the following actions should the nurse take?
A. Request a prescription for magnesium citrate.
B. Request a prescription for furosemide.
C. Place the client on a low-calcium diet.
D. Place the client on seizure precautions.
D. Place the client on seizure precautions.
A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the following actions should the nurse take?
A. Encourage the client to rest quietly in bed twice per day.
B. Direct long conversations about the delusions toward reality-based topics.
C. Allow the client unlimited time to discuss the delusions when they occur.
D. Avoid assessing the client’s delusions.
B. Direct long conversations about the delusions toward reality-based topics.
A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?
A. Asthma
B. Fibromyalgia
C. Hypertension
D. Fibrocystic breast condition
C. Hypertension
A nurse in the emergency department is triaging victims of a house fire. Which of the following clients should the nurse prioritize as emergent?
A. Client who has a compound fracture of the femur
B. Client who has hypertension and reports chest pain
C. Client who has severe abdominal pain
D. Client who has a deep laceration on both thighs
B. Client who has hypertension and reports chest pain
A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively?
A. Gather supplies prior to completing a dressing change.
B. Complete partial assessments on all clients before planning the day.
C. Prioritize activities based on the nurse’s needs.
D. Use break time to perform documentation.
A. Gather supplies prior to completing a dressing change.
A nurse on a mental health unit is planning room assignments for four clients. Which of the following clients should the nurse assign to room near the nurse’s station?
A. A client who has a somatic symptom disorder and reports chronic pain.
B. A client who has an anxiety disorder and is experiencing moderate anxiety.
C. A client who has bipolar disorder and impaired social interactions.
D. A client who has a depressive disorder and reports feeling hopeless.
D. A client who has a depressive disorder and reports feeling hopeless.
A nurse is assessing coping strategies of a client whose partner has alcohol use disorder. Which of the following findings indicates that the client is coping effectively?
A. The client utilizes strategies to enhance codependent behaviors.
B. The client attends regular counseling sessions.
C. The client exhibits sympathy to the partner.
D. The client ignores the partner when they are using alcohol.
B. The client attends regular counseling sessions.
A nurse is caring for a client who has Graves’ disease and is experiencing a thyroid storm. Which of the following actions is the nurse’s priority?
A. Obtain the client’s blood glucose.
B. Administer 0.9% sodium chloride IV.
C. Provide a cooling blanket.
D. Monitor the client’s cardiac rhythm. This has more priority
D. Monitor the client’s cardiac rhythm. This has more priority
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
A. “Remain on bed rest for 24 hours following the procedure.”
B. “Use an incentive spirometer every 4 hours.”
C. “Participate in range-of-motion exercises.”
D. “Place a pillow under your knees while in bed.”
C. “Participate in range-of-motion exercises.”
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse when pouring the sterile solution?
A. Hold the bottle in the center of the sterile field when pouring the solution.
B. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
C. Place the sterile gauze over areas of spilled solution within the sterile field.
D. Remove the cap and place it sterile-side up on a clean surface
D. Remove the cap and place it sterile-side up on a clean surface
A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the back of the legs of one of the children. Which of the following actions should the nurse take first?
A. Contact child protective services.
B. Refer the parents to a self-help group.
C. Instruct the parents about methods of discipline.
D. Document clinical findings.
A. Contact child protective services.
A nurse is teaching a client who is to undergo placement of a non-tunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching?
A. “The provider will wear a mask while performing the procedure.” B. “You should not eat or drink for 4 hours prior to the procedure.”
C. “Your head will be elevated as high as possible while the
catheter is inserted.”
D. “The provider will give you pain medication before inserting the catheter.”
A. “The provider will wear a mask while performing the procedure.”
A nurse in a clinic is reviewing the health history of a client during her first prenatal visit. Which of the following findings indicates a risk for gestational diabetes mellitus?
A. 1-hr glucose tolerance test if 128 mg/dL
B. Previous miscarriage
C. Delivery of a low birth-weight infant
D. BMI of 31
D. BMI of 31
A nurse is caring for a client who is incontinent and has a stage II pressure injury on their coccyx. Which of the following interventions should the nurse implement?
A. Apply lotion to the skin every 4 hr.
B. Reposition the client every 3 hr.
C. Position the client laterally at 30 degrees.
D. Have two facility personnel help to slide the client up in bed.
D. Have two facility personnel help to slide the client up in bed.
A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as the clinic staff. Which of the following instructions should the nurse include?
A. Offer clients translation services for a nominal fee.
B. Use clients’ children to provide interpretation.
C. Evaluate clients’ understanding at regular intervals.
D. Direct questions to a medical interpreter.
C. Evaluate clients’ understanding at regular intervals.
A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to provide cost-effective care?
A. Leave the unused infusion pump in the room until discharge.
B. Bring in formula as needed.
C. Return unopened equipment to the supply center.
D. Stock the room with a 2-day supply of disposable diapers.
B. Bring in formula as needed.
A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the following prescriptions should the nurse expect the provider to prescribe?
A. Interferon beta-1a
B. Enoxaparin
C. Atorvastatin
D. Amoxicillin
A. Interferon beta-1a
A nurse is speaking with the partner of a client who is in the early stage of Alzheimer’s disease. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want toleave him home alone while she travels for work. Which of the following referrals should the nurse make?
A. Respite care
B. Restorative care
C. Hospice
D. Rehabilitation facility
A. Respite care
A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?
A. Orthostatic hypotension
B. Decreased respirations
C. Polyuria
D. Bradycardia
A. Orthostatic hypotension
A nurse is caring for a client who is at 14 weeks of gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
A. “When did you start having these feelings?”
B. “Have you discussed these feelings with your partner?”
C. “You should discuss your feelings about being pregnant with your provider.”
D. “Describe your feelings to me about being pregnant.”
D. “Describe your feelings to me about being pregnant.”
A nurse manager is planning to promote client advocacy among staff on a medical unit. Which of the following actions should the nurse plan to take?
A. Instruct unit staff to share personal experiences to help clients make decisions.
B. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice.
C. Develop a system for staff members to report safety concerns in the client care environment.
D. Tell staff to explain procedures to clients before obtaining informed consent.
C. Develop a system for staff members to report safety concerns in the client care environment.
A nurse received a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide for the parent?
A. “Place a warm, wet washcloth over your child’s forehead and the bridge of their nose.”
B. “Tell your child to blow their nose gently, and then sit down and tilt their head backward.”
C. “Use your thumb and forefinger to apply pressure to the sides of your child’s nose.”
D. “Have your child lie down and turn their head to the side for 10 minutes.”
C. “Use your thumb and forefinger to apply pressure to the sides of your child’s nose.”
A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care?
A. Hgb 15 g/dL.
B. Appearance of pink tissue under eschar.
C. Albumin level 4.0 g/dL
D. Weight loss of 5% in 10 days.
D. Weight loss of 5% in 10 days.
A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?
A. Inspection
B. Palpation
C. Auscultation
D. Percussion
B. Palpation
A nurse is caring for a client who has an NG tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?
A. Check the functioning of the suction equipment.
B. Reposition the NG tube.
C. Instill an irrigation solution slowly.
D. Inject 20 mL of air and aspirate in the NG tube
A. Check the functioning of the suction equipment.
A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client’s condition is improving?
A. The client avoids eye contact with others.
B. The client exhibits a flat affect.
C. The client participates in self-care.
D. The client experiences self-doubt when making decisions.
C. The client participates in self-care.
A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next?
A. Provide the client with an instructional handout about swallowing exercises.
B. Ask a speech therapist to evaluate the client’s ability to swallow.
C. Discuss the manifestations of impaired swallowing with the AP.
D. Listen to the client’s lung sounds.
D. Listen to the client’s lung sounds.
A nurse in an acute mental health facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A. A client who has obsessive-compulsive disorder and is upset about change in daily routine
B. A client who has depressive disorder and requires assistance with ADLs C.
A client who has narcissistic personality disorder and is mocking others during group therapy
D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel (AP). Which of the following statements should the nurse include in the teaching?
A. “The RN evaluates client needs to determine tasks to delegate.”
B. “An AP can perform tasks outside of his range of function if he has been trained.”
C. “An experienced AP can delegate tasks to another AP.”
D. “The RN is legally responsible for the actions of the AP.”
A. “The RN evaluates client needs to determine tasks to delegate.”
A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?
A. Memory loss
B. Hypotension
C. Elevated temperature
D. Slurred speech
C. Elevated temperature
A nurse administered 400mg of ibuprofen to a client 2 hr ago to treat pain following a biopsy. The client is crying and states, “It really still hurts a lot.” Which of the following actions should the nurse take?
A. Administer an additional dose of ibuprofen to the client.
B. Request a prescription for an opioid pain medication for the client.
C. Report this client finding to the provider.
D. Ask the client to rate their pain on a scale of 0 to 10.
D. Ask the client to rate their pain on a scale of 0 to 10.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (SATA) A. Allow the client to choose among a variety of activities each day
B. Refute the client’s delusions using logic.
C. Establish eye contact when communicating with the client.
D. Reinforce orientation to time, place, and person.
E. Give the client one simple direction at a time.
C. Establish eye contact when communicating with the client.
D. Reinforce orientation to time, place, and person.
E. Give the client one simple direction at a time.
A nurse is providing nutritional teaching to a client who is experiencing severe nausea. Which of the following responses by the client indicates an understanding of the teaching?
A. “I should increase my intake of liquids with meals.”
B. “I should focus on eating complex carbohydrates.”
C. “I should lie down after my meals.”
D. “I should sip on clear carbonated beverages that have gone flat.”
B. “I should focus on eating complex carbohydrates.”
A nurse is providing teaching about disulfiram to a client who has alcohol use disorder. Which of the following statements should the nurse make?
A. “Wait at least 12 hr after your last drink to take this medication.”
B. “Alcohol should not be consumed for 3 days following your last dose.”
C. “This medication will decrease your risk for delirium during your withdrawal from alcohol.”
D. “This medication will prevent seizures during your withdrawal from alcohol.”
B. “Alcohol should not be consumed for 3 days following your last dose.”
A nurse is assessing a client following an ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?
A. The client reports a metallic taste in his mouth.
B. The client has poor-fitting dentures.
C. The client reports a decreased appetite.
D. The client coughs after swallowing.
D. The client coughs after swallowing.
A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?
A. Limit the client’s opportunities to socialize with others.
B. Mix the medication with the client’s food items.
C. Rotate staff members caring for the client.
D. Speak in a neutral tone when addressing the client
D. Speak in a neutral tone when addressing the client
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
A. Report of discomfort at the insertion site.
B. Hematoma over the insertion site.
C.
D. Bounding pulses in the affected extremity.
E. Heart rate 90/min
B. Hematoma over the insertion site.
A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?
A. Have the client store smaller tanks under his bed.
B. Place the oxygen tank away from curtains or drapes.
C. Ensure that the client checks the gauge weekly.
D. Store the oxygen tank wrench in a locked cabinet.
B. Place the oxygen tank away from curtains or drapes.
A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching.
A. “I don’t need to use a walker when walking around my house.”
B. “I will start my leg exercises 3 days after returning home.”
C. “I won’t cross my legs when sitting in a chair.”
D. “I will bend at the hips when tying my shoes.”
C. “I won’t cross my legs when sitting in a chair.”
A nurse is teaching a client about the oral administration of chlorpromazine. Which of the following information should the nurse include?
A. Move slowly when standing from a sitting position.
B. Expect loose stools as an adverse effect.
C. Anticipate an increase in saliva production.
D. Monitor for an increase in the occurrence of hiccups
A. Move slowly when standing from a sitting position.
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?
A. Assess the fetal heart rate.
B. Discontinue the infusion.
C. Administer calcium gluconate.
D. Obtain the client’s magnesium level.
B. Discontinue the infusion.
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report to the provider?
A. BUN mg/dL
B. Urine specific gravity 1.023
C. Serum creatinine 1.6 mg/dL
D. Urine pH 6.2
C. Serum creatinine 1.6 mg/dL
A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?
A. Allow the client to walk unassisted near the nursing station.
B. Establish an elimination schedule for the client.
C. Silence the bed alarm when visitors are at the client’s bedside.
D. Raise all four bed rails on the client’s bed.
B. Establish an elimination schedule for the client.
A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?
A. Asks security to detain the client until the provider is notified.
B. Asks the client what her plans are for follow-up care.
C. Shows the client her abnormal laboratory results.
D. Asks the client to sign a form releasing the hospital from legal responsibility.
A. Asks security to detain the client until the provider is notified.
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following nursing interventions should the nurse include in the plan of care for this client?
A. Flush IV tubing with hypotonic solution.
B. Encourage oral hydration of 1,800mL daily
C. Perform neurologic checks.
D. Weigh the client weekly
C. Perform neurologic checks.
A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?
A. Check the cords of the IV pump for fraying.
B. Grasp the IV pump cord when unplugging it from the electrical outlet.
C. Remove the safety inspection sticker before plugging in the IV pump.
D. Ensure that the electric outlet has two prongs for the IV pump.
A. Check the cords of the IV pump for fraying.
A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?
A. Nurses should discontinue the critical pathway if variances occur. B. Nurses’ notes are used to create the critical pathway.
C. Critical pathways should reduce health care costs.
D. Critical pathways have an unlimited timeframe for completion.
C. Critical pathways should reduce health care costs.
A nurse is providing teaching to a client who has otitis media and is 1 hr postoperative following a myringotomy. Which of the following statements should the nurse include in the teaching?
A. “You should not drink through a straw for 2 weeks.”
B. “You can wash your hair 3 days after the procedure.”
C. “You should blow your nose with your mouth closed.”
D. “You should expect excessive ear drainage for about 48 hours.”
A. “You should not drink through a straw for 2 weeks.”
A nurse is teaching a newly licensed nurse about incidents reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “They assist with unit quality improvement.”
B. “They are used as a disciplinary tool for nurse evaluations.”
C. “They assist the facility to achieve benchmark goals.”
D. “They are mandatory government documentation.”
A. “They assist with unit quality improvement.”
A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
A. Decrease socialization with extended relatives until roles are identified.
B. Encourage authoritative communication from the adult child.
C. Minimize open discussion regarding the changes to avoid embarrassment.
D. Implement firm but flexible boundaries in their relationship.
D. Implement firm but flexible boundaries in their relationship.
A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care?
A. Ask the client to shift his weight every 20 min while sitting in a chair.
B. Massage reddened areas over bony prominences.
C. Maintain the head of the bed at a 45-degree angle.
D. Provide a high-fiber diet for the client.
A. Ask the client to shift his weight every 20 min while sitting in a chair.
A nurse in a provider’s office is reviewing the laboratory results of group clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
A. Chlamydia
B. Candidiasis
C. Herpes simplex virus
D. Human papillomavirus.
A. Chlamydia
A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?
A=. “You should avoid vaginal spermicides while breastfeeding.”
B. “The lactation amenorrhea method is effective for your first year postpartum.”
C. “Place the transdermal birth control patch on your upper outer arm.”
D. “You can continue to use the diaphragm you used before your pregnancy.”
C. “Place the transdermal birth control patch on your upper outer arm.”
A nurse is caring for a client who is 12 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
A. Burgundy-colored urine
B. Report of pain level 5 on a scale of 0 to 10.
C. Passage of small clots.
D. Urgency to void
C. Passage of small clots.
A nurse is caring for a client who is receiving enteral feedings through a nasoenteric tube and has aspirated fluid prior to feeding. Which of the following findings should indicate to the nurse that the tube is positioned in the client’s lung?
A. Residual fluid with a pH of 1
B. Residual fluid with a pH of 8
C. Residual fluid with a pH of 6
D. Residual fluid with a pH of 3
B. Residual fluid with a pH of 8
A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure?
A. Trendelenburg
B. Prone
C. Right lateral
D. High-fowler’s
C. Right lateral
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
A. Keep visitors at least 6 feet (1.8 m) away from the client.
B. Place the client’s soiled bed linens in a biohazard bag outside the client’s room.
C. Wear an isolation gown when caring for the client.
D. Discard the radioactive source in the client’s trash can.
A. Keep visitors at least 6 feet (1.8 m) away from the client.
A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority consult?
A. Speech-language pathologist
B. Dietitian
C. Occupational therapist
D. Physical therapist
A. Speech-language pathologist
A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the entries should the nurse make in the medical record?
A. “Morphine 3 mg SC q 4 hr PRN for pain.”
B. “Morphine 3 mg SQ every 4 hr PRN for pain.”
C. “Morphine 3 mg subcutaneous every 4 hr PRN for pain.”
D. “Morphine 3.0 mg sub q every 4 hr PRN for pain.”
C. “Morphine 3 mg subcutaneous every 4 hr PRN for pain.”
A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? A. Wear sterile gloves to collect the specimen from the client.
B. Obtain the specimen immediately upon the client waking up.
C. Wait 1 day to collect the specimen if the client cannot provide sputum.
D. Ask the client to provide 15 to 20 mL of sputum into the container
B. Obtain the specimen immediately upon the client waking up.
A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will place a ticking clock nearby to soothe my baby throughout the day.”
B. “I can use a firm pillow to prop up the bottle when feeding my baby.”
C. “I will avoid picking up my baby too often to keep from spoiling him.”
D. “I will hang a pastel-colored mobile 24 inches above my baby’s crib.”
A. “I will place a ticking clock nearby to soothe my baby throughout the day.”
A nurse is planning care for a client who has COPD and weight loss. Which of the following interventions should the nurse include in the plan?
A. Schedule a large meal in the evening.
B. Provide high-protein nutritional supplements.
C. Offer hot fluids along with meals.
D. Encourage the client to eat toast for breakfast
B. Provide high-protein nutritional supplements.
A nurse is providing teaching to an older client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include?
A. “Limit foods that contain vitamin D while taking this medication.” B. “Plan to take this medication with food.”
C. “Limit foods that contain folic acid while taking this medication.” D. “Plan to take this medication with antacids.”
B. “Plan to take this medication with food.”
A nurse is reviewing the facility’s safety protocols concerning newborn abduction with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching?”
A. “I will not publish a public announcement about my baby’s birth.”
B. “Staff will apply identification bands to my baby after her first bath.”
C. “I can leave my baby in my room while I walk in the hallway.”
D. “I can remove my baby’s identification band as long as she is in my room.”
A. “I will not publish a public announcement about my baby’s birth.”
A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client that she will undergo which the following screening tests at 16 weeks of gestation?
A. Cervical cultures for chlamydia
B. Chorionic villus sampling
C. Maternal serum alpha-fetoprotein
D. Nonstress test
C. Maternal serum alpha-fetoprotein
A nurse is providing nutritional teaching about appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following foods should the nurse include in the teaching?
A. Liver
B. Roast beef
C. Chicken
D. Lima beans
D. Lima beans
A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?
A. Use short sentences when communicating with the client.
B. Have the client journal about what is happening to him.
C. Tell the client to sit alone in a private place and reflect on the situation.
D. Encourage the client to talk about his feeling
A. Use short sentences when communicating with the client.
A nurse is teaching a client about advance directives. Which of the following statements should the nurse make?
A. “A family member will need to cosign the advance directives document.”
B. “An attorney will need to review your advance directives.”
C. “Advance directives can include a do-not-resuscitate order signed by the provider.”
D. “A health care surrogate will handle your medical bills.”
C. “Advance directives can include a do-not-resuscitate order signed by the provider.”
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
A. Sneezing
B. Substernal retractions
C. Temperature 37.9 degrees (100.2 F)
D. Hematuria
B. Substernal retractions
A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect?
A. Paradoxical chest movement
B. Bilateral crackles
C. Asymmetry of the chest
D. Blood-tinged sputum
C. Asymmetry of chest
A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse recommend?
A. Human papillomavirus
B. Influenza
C. Measles, mumps and rubella
D. Varicella
B. Influenza
A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child. Which of the following findings should the nurse report to the provider?
A. Hct 40%
B. Hgb 12.5 g/dL
C. Platelets 250,000/mm
D. WBC 14,000/mm
D. WBC 14,000/mm
A nurse is assessing a client who is receiving packed RBCs. Which of the following indicates fluid overload?
A. Low-back pain
B. Thready pulse
C. Hypotension
D. Dyspnea
D. Dyspnea
A nurse is caring for an adult client who asks about risk factors for Alzheimer’s disease. Which of the following responses should the nurse take?
A. “There are no known genetic mutations that cause Alzheimer’s disease.”
B. “A diet low in carbohydrates increases the risk for Alzheimer’s disease.”
C. “Asthma has been identified as a risk factor for Alzheimer’s disease.”
D. “Repeated concussions increase the risk for Alzheimer’s disease.”
Repeated concussions
A community health nurse is developing a plan to improve the community’s environmental health. Which of the following actions should the nurse take first?
A. Collect information about the community’s environmental status. B. Request funding from community organizations.
C. Establish a timeframe for environmental improvements.
D. Encourage community involvement in the environmental improvement.
A. Collect information about the community’s environmental status.
A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following information should the nurse include about preventing the spread of infection?
A. Use condoms with petroleum-based lubricant.
B. Buy disposable dishes for daily use.
C. Clean blood-contaminated surfaces with bleach.
D. Wash soiled clothes in cold water.
C. Clean blood-contaminated surfaces with bleach.
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
A. Avoid preparing medications for more than two clients at one time.
B. Inform clients about the action of the medication of the medication prior to administration.
C. Read medication labels at least two times prior to administration. D. Complete an incident report if a client vomits after taking a medication.
B. Inform clients about the action of the medication of the medication prior to administration.
A nurse in a pediatric clinic is assessing a 6-month old infant. Which of the following findings should the nurse identify as a possible indication of neglect?
A. Inability to sit without support.
B. A capillary hemangioma on the buttocks.
C. Current weight twice the infants birth weight.
D. Lack of social smile.
D. Lack of social smile.
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the disease, the nurse should identify which of the following electronic databases has the most comprehensive collection of nursing journal articles?
A. MEDLINE B. CINAHL C. Health science D. ProQues
B. CINAHL
A nurse in a provider’s office is assessing a client for melanoma. Which of the following findings should the nurse report to the provider?
A. Red, pustular lesions on the face
B. Circular, brown plaques on the arms
C. Round, light tan pigmented spots on the face
D. Red-blue papule on the upper bac
B. Circular, brown plaques on the arms
A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?
A. Restlessness
B. Mottled skin
C. Constricted pupils
D. Cheyne-stokes respiration
A. Restlessness
A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?
A. Oral
B. Axillary
C. Tympanic
D. Rectal
B. Axillary
A nurse is preparing to administer vancomycin IV to a client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
A. “I can start the medication 30 minutes earlier.”
B. “I have up to 2 hours after the usual schedule time to give you this medication.”
C. “I can infuse the medication at a faster rate.”
D. “I can adjust the time and schedule for when it’s convenient for you.”
A. “I can start the medication 30 minutes earlier.”
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse take?
A. Elevate the client’s arm prior to insertion.
B. Select a site on the client’s dominant arm.
C. Apply a tourniquet below the venipuncture site.
D. Choose a vein that is palpable and straight.
D. Choose a vein that is palpable and straight.
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemisphere stroke. Which of the following interventions should the nurse include in the plan?
A. Place the client’s left arm on a pillow while he is sitting.
B. Maintain the client on bed rest.
C. Provide total care in performing the client’s ADLs.
D. Place food on the left side of the client’s mouth when he is ready to eat.
A. Place the client’s left arm on a pillow while he is sitting.
A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of the steps the nurse manager should plan to take in response to the staff member’s conduct. (Move steps into the box on to the right, placing them in order of performance. Use all steps.)
- Verbally remind the staff member of the expected behavior changes.
- Give the staff member a written warning about the behavior.
- Set up a meeting to speak with the staff member about the behavior.
- Suspend the staff member from work for several days.
- Dismiss the staff member from employment at the facility.
- Verbally remind the staff member of the expected behavior changes.
- Give the staff member a written warning about the behavior.
- Set up a meeting to speak with the staff member about the behavior.
- Suspend the staff member from work for several days.
- Dismiss the staff member from employment at the facility.
A nurse is teaching a client who has chronic urinary tract infections. Which of the following instructions should the nurse include?
A. Take tub baths instead of showers
B. Wipe from back to front after a bowel movement.
C. Drink at least 1 L of fluid every day.
D. Try to void every 4 hr.
D. Try to void every 4 hr.
A nurse is caring for a newly admitted client who has a history of expressive aphasia. Which of the following actions should the nurse take?
A. Speak loudly when facing the client.
B. Apply a safety monitoring device on the client’s bed.
C. Use a picture board to communicate with the client.
D. Provide the client with an artificial voice box.
C. Use a picture board to communicate with the client.
A nurse in a long-term care facility is caring for a client who has Alzheimer’s disease. The client’s partner asks why the client started taking memantine instead of donepezil. Which of the following responses should the nurse make?
A. “Memantine improves cognitive function in later stages of Alzheimer’s.”
B. “Memantine helps prevent seizures in clients who have Alzheimer’s.”
C. “Memantine is an herbal alternative to donepezil.”
D. “Memantine is an extended-release version of donepezil.”
A. “Memantine improves cognitive function in later stages of Alzheimer’s.”
A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take?
A. Contact the client’s family about the incident.
B. Report the incident to the AP’s charge nurse.
C. File a complaint with the facility’s ethics committee.
D. Notify the client’s provider about the incident.
B. Report the incident to the AP’s charge nurse.
A nurse is teaching a client who has AIDS and is immunosuppressed about food safety. Which of following information should the nurse include in the teaching?
A. Plan to eat poultry within 3 days of refrigeration.
B. Store perishable foods in the refrigerator at 8.9 degrees C (48 F)
C. Defrost frozen food in the refrigerator before preparation.
D. Eat leftover foods within 5 to 7 days of preparation
C. Defrost frozen food in the refrigerator before preparation.
A nurse is teaching a client about do-not-resuscitate (DNR) orders. Which of the following information should the nurse include in the teaching?
A. The presence of a DNR order indicates that there is no conflict between the client and the family’s wishes.
B. A client can verbally request a DNR order from the provider.
C. A DNR order indicates that the client cannot be prescribed new medications or treatments.
D. Once a DNR order has been implemented, it cannot be changed.
B. A client can verbally request a DNR order from the provider.
A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will need to lose 25 percent of my excess body weight prior to surgery.”
B. “I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after surgery.”
C. “I will consume 48 ounces of carbonated beverages daily prior to the surgery.”
D. “I should wait 30 minutes after eating solid foods to drink beverages following surgery.”
A. “I will need to lose 25 percent of my excess body weight prior to surgery.”
A director of nursing in a rehabilitation facility is planning to measure the quality of care provided. Which of the following audits should the director plan to use after clients are discharged to gather information about quality of care?
A. Structure audit
B. Concurrent audit
C. Outcome audit
D. Prospective audit
C. Outcome audit
A charge nurse is assessing client care tasks for the upcoming shift. Which of the following tasks should the charge nurse assign to an RN?
A. Obtaining blood cultures from a central catheter
B. Inserting an endotracheal tube
C. Inserting an epidural catheter
D. Performing a thoracentesis
A. Obtaining blood cultures from a central catheter
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin?
A. Glargine insulin
B. Insulin aspart
C. NPH insulin
D. Regular insulin
A. Glargine insulin
A nurse is assessing a client who is on bed rest and notes on calf is 2.5 cm (1 inch) larger in diameter than the other calf. Which of the following actions should the nurse take?
A. Place the client’s legs in a dependent position.
B. Apply a warm, moist soak to the larger calf.
C. Massage the larger calf.
D. Restrict the client’s fluid intake
A. Place the client’s legs in a dependent position.
A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
A. Contractions every 5 min that last 30 seconds
B. Montevideo units consistently 300 mm Hg
C. Urine output of 20mL/hr
D. FHR pattern with absent variability
A.
A nurse is screening food brought in by a family member for a client who takes phenelzine. The nurse should instruct the family member that which of the following foods can cause an interaction with this medication?
A. Cottage cheese
B. Iceberg lettuce salad
C. Orange gelatin
D. Bologna sandwich
D. Bologna sandwich
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
A. Digoxin 0.25mg PO daily
B. Cimetidine PO twice daily
C. Epoetin alfa 150 units/kg three times weekly
D. Tetracycline 200mg PO
A. Digoxin 0.25mg PO daily
A nurse is collecting a medication history from a client who reports taking aspirin 81 mg daily. Which of the following medications places the client at increased risk for bleeding?
A. Potassium chloride
B. Gabapentin
C. Dabigatran
D. Pioglitazone
Dabigatran
A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 1 min with a 45-second duration, and the fetal heart rate is 170 to 180/min. Which of the following actions should the nurse take?
A. Relieve pressure on the umbilical cord.
B. Discontinue the oxytocin infusion.
C. Apply an internal fetal monitor.
D. Administer calcium gluconate.
B. Discontinue the oxytocin infusion.
A nurse is preparing to obtain a client’s signature on an informed consent form. Which of the following actions should the nurse take first?
A. Inform the client of his right to change his mind.
B. Witness the client signing the informed consent form.
C. Notify the provider if the client has questions about the procedure.
D. Ask the client to explain his understanding of the procedure.
D. Ask the client to explain his understanding of the procedure.
A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?
A. Speak in a loud tone when addressing the client.
B. Remind the client to eat scheduled meals daily.
C. Place the client in a supine position.
D. Offer the client a blanket to keep warm.
D. Offer the client a blanket to keep warm.
A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
A. Heart rate 140/min
B. Capillary refill 3 seconds
C. Cessation of nocturnal enuresis
D. Absence of hypoglycemic episodes
C. Cessation of nocturnal enuresis
A nurse in an emergency department is caring for a client who has received a dose of penicillin and is now anxious, flushing, tachycardic, and having difficulty swallowing. Which of the following actions is the nurse’s priority?
A. Take the client’s vital signs.
B. Administer oxygen.
C. Insert an IV line.
D. Monitor the client’s ECG.
A. Take the client’s vital signs.
A nurse is caring for an adolescent who has ADHD. Which of the following findings should the nurse report to the provider? (EXHIBIT)
A. WBC count
B. Oxygen saturation
C. Aspartate aminotransferase (AST)
D. Weight
C. Aspartate aminotransferase (AST)
A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider?
A. Temperature 37.8 degrees (100 F)
B. Heart rate 100/min
C. Albumin level 4.0 g/dL
D. WBC count 14,000 mm
D. WBC count 14,000 mm
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?
A. Drink 1.5 L of fluids each day.
B. Take mineral oil at bedtime.
C. Increase exercise activity.
D. Decrease insoluble fiber intake.
C. Increase exercise activity.
A nurse is administering a medication to a client. The client reports the medication appears different then what they take at home. Which of the following responses should the nurse make?
A. “I recommend that you take this medication as prescribed.”
B. “I will call the pharmacist now to check on this medication.”
C. “Did the doctor discuss with you that there was a change in this medication?”
D. “Do you know why this medication is being prescribed for you?
B. “I will call the pharmacist now to check on this medication.”
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
A. Isolate the client from staff who are pregnant.
B. Administer aspirin to the client.
C. Initiate airborne precautions.
D. Monitor for the development of Koplik spots.
A. Isolate the client from staff who are pregnant.
PICTURE OF GUYS FACE – ANSWER: (C, UNDER EYE)
PICTURE OF GUYS FACE – ANSWER: (C, UNDER EYE)
A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?
A. Have the child take a tub bath each morning.
B. Apply splints to the child’s extremities during the day.
C. Encourage the child to take naps during the day.
D. Keep the child on bedrest as long as pain persists.
C. Encourage the child to take naps during the day.
A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following alterations in the client’s condition should the nurse identify as an indication of the development of a pneumothorax?
A. Pallor
B. Tracheal deviation
C. Slow respirations
D. Bradycardia
B. Tracheal deviation
A nurse is caring for a client who is experiencing cerebral edema. Which of the following actions should the nurse take?
A. Administer corticosteroids
B. Perform multiple nursing activities at one time.
C. Place the client in a prone position.
D. Assess the client for a positive Trousseau sign
B. Perform multiple nursing activities at one time.
A nurse is caring for a school-age child who has sickle-cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take?
A. Place the child on bed rest.
B. Decrease the child’s oral fluid intake.
C. Administer meperidine to the child.
D. Apply cold compresses to the child’s joints
C. Administer meperidine to the child.
A nurse is providing teaching about the administration of gastronomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse include?
A. Administer the feeding over 30 min.
B. Change the feeding bag and tubing every 3 days
C. Warm the formula in the microwave prior to administration
D. Place the child in a supine position after the feeding.
A. Administer the feeding over 30 min.
A nurse is caring for a client who has a fracture of the left hip and is in skeletal traction. Which of the following actions should the nurse take?
A. Increase the amount of weight if the client experiences muscle spasms.
B. Remove the traction weights when bathing the client.
C. Ensure there is no space between the traction weights and the bed.
D. Provide a trapeze for the client to aid movement in bed.
D. Provide a trapeze for the client to aid movement in bed.
A nurse who is trained as an interpreter has agreed to translate for an older adult client who is assigned to another nurse. Which of the following statements by the nurse who is translating indicates understanding of this role?
A. “I will let the client know that I am available as the interpreter.”
B. “I will receive a small fee for interpreting for this client.”
C. “I will let the client know that an interpreter is unavailable during the night shift.”
D. “I am glad I am available today, but when I’m not, you can use a family member.”
A. “I will let the client know that I am available as the interpreter.”
A nurse on an inpatient eating disorder unit is assessing an adolescent client who has anorexia nervosa and a BMI of 16.5. Which of the following findings should the nurse expect?
A. Menorrhagia
B. Potassium 4.2 mEq/L
C. Blood pressure 132/86 mm Hg
D. Lanug
A. Menorrhagia / D Lanugo
A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make?
A. “Your bladder should be full prior to me performing this test.”
B. “I will be taking a blood sample to test for changes in your hormone levels.”
C. “This test will determine if there is leaking amniotic fluid.”
D. “If this test is positive you will be required to have a non-stress test.”
C. “This test will determine if there is leaking amniotic fluid.”
A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which of the following information should the nurse include in the teaching?
A. “You should eat hot foods to reduce your sense of fullness during a meal.”
B. “Lunch should be your largest meal of the day.”
C. “During meals, you should eat foods with a high-calorie content first.”
D. “While eating, you should drink liquids frequently.”
C. “During meals, you should eat foods with a high-calorie content first.”
A nurse is teaching a client who has GERD and a new prescription for omeprazole delayed-release capsules. Which of the following statements by the client indicates an understanding of the teaching?
A. “I can expect my hands to have tremors while taking this medication.”
B. “I should take this medication before my first meal of the day.”
C. “I should decrease my calcium intake while taking this medication.”
D. “I can expect to have black, tarry stools while taking this medication.”
B. “I should take this medication before my first meal of the day.”
A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
A. Head circumference exceeds chest circumference.
B. Nontender, protruding abdomen
C. Natural loss of deciduous teeth.
D. Palpable fontanels
B. Nontender, protruding abdomen
A charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter for a female client. Which of the following actions by the nurse requires intervention by the charge nurse?
A. Places the sterile field on a table that remains within her site.
B. Opens the sterile kit by unfolding the flap closest to her first.
C. Provides perineal care prior to opening the catheter kit using clean gloves.
D. Uses nondominant hand to expose urethral meatus by spreading the labia.
B. Opens the sterile kit by unfolding the flap closest to her first.