The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
B. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
A. Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
A. Instructions about how much fluid the child should drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot).
I placed the red dot on the base of the neck on the right side
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing abdominal distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
D. Respiratory alkalosis
A client with dyspnea is being admitted to the medical unit. To best prepare for the client’s arrival, the nurse should ensure that the client’s bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
Fowlers
The nurse is taking the blood pressure measurement of a client with Parkinson’s disease. Which information in the client’s admission assessment is relevant to the nurse’s plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
A. Frequent syncope
C. Flat affect
D. Blurred vision
While caring for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
B. Ask the older brother how he felt during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved
A. Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload
B. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light
B. Minimize the amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch
C. Had a cold and ear infection for the past two days
A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?
A. The impending signs of death should be documented
B. The client’s status should be conveyed to the chaplain
C. The client’s need for pain medication should be determined
D. The nurse manager should be updated on the client’s status
C. The client’s need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan
B. Blood glucose monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure
A. Apply ice to the breasts for comfort
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water
B. Use a residual limb shrinker
D. Inspect skin for redness
E. Wash the stump with soap and water
A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler’s family about?
A. Serum immunoglobulin E (IgE)
B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge
A. Serum immunoglobulin E (IgE)
A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the highest priority?
A. Allow client to gargle with warm salt water
B. Administer a sedative to alleviate anxiety
C. Instruct client to write down the questions
D. Deny client’s request for a midnight snack
C. Instruct client to write down the questions
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
A. Notify the nurse when the transfusion has finished, so further client assessment can be done
B. Continue to measure the client’s vital signs every thirty minutes until the transfusion is complete
C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
B. Continue to measure the client’s vital signs every thirty minutes until the transfusion is complete
The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care?
A. Assess warmth of extremities
B. Keep head of bed raised 45 degrees
C. Monitor blood glucose level
D. Maintain strict intake and output
D. Maintain strict intake and output
A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client’s pain, which approach should the nurse use?
A. Ask the client to describe the pain
B. Observe body language and movement
C. Identify effective pain relief measures
D. Provide a numeric pain scale
A. Ask the client to describe the pain
A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring
D. Begin continuous fetal monitoring
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test
B. Increase physical activity
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously over 4 hours. The IV administration set delivers 10gtt/mL. How many gtt/minute should the nurse regulate the infusion? (Round to the nearest whole number)
42 gtt/min
Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client’s plan of care?
A. observe color of urine
B. Measure body temperature
C. Assess skin turgor
D. Check for pedal edema
A. Observe color of urine
A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client’s health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip
D. The client fell sustaining a fracture to the left hip
The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis?
A. Barking cough and vomiting
B. Mucopurulent cough and night sweats
C. Dry cough and chest tightness
D. Chronic cough and fatty stools
B. Mucopurulent cough and night sweats
In assessing a client with type 1 diabetes mellitus, the nurse notes that the client’s respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client become lethargic. Which assessment data should the nurse obtain next?
A. Temperature
B. Breath sounds
C. Blood glucose
D. White blood cell count
C. Blood glucose
A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client’s perineal pad hourly and that it is again saturated. The previous nurse also reports that the client’s urinary output has decreased. Which action should the nurse implement first?
A. Evaluate the skin turgor
B. Assess for weakness or dizziness
C. Change the perineal pad
D. Measure the urinary output
B. Assess for weakness or dizziness
The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?
A. Reassure the client that his child will be allowed to visit
B. Provide the client written information about end-of-life care
C. Obtain a detailed report from the nurse transferring the client
D. Mark the chart with client’s request for no heroic measures
C. Obtain a detailed report from the nurse transferring the client
While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?
A. Obtain sputum sample
B. Document degree of edema
C. Initiate hourly urine output measurement
D. Administer intravenous diuretics
A. Obtain sputum sample
A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (descending order)
- Observe breathing patterns
- Assess blood pressure
- Measure body temperature
- Palpate for pedal edema
A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?
A. Potassium 3.5 mEq/L
B. Fingertips feel numb
C. Sodium 135 mEq/L
D. Cervical spine stiffness
B. Fingertips feel numb
An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client’s daughter, who has power of attorney, has brought the client’s prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication?
A. currently prescribed medications
B. Client’s healthcare power of attorney
C. Increasing confusion of the client
D. Fall at home as reason for admission
C. Increasing confusion of the client
The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement?
A. Auscultate for irregular heart rate
B. Review arterial blood gases results
C. Measure ankle circumference
D. Document abdominal girth
A. Auscultate for irregular heart rate
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)
A. Administer a dose of insulin per sliding scale for a client with Type 2 DM
B. Start the second blood transfusion for a client 12 hours following a BKA
C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively
D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
A. Administer a dose of insulin per sliding scale for a client with Type 2 DM
D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
A. Core strengthening
B. Aerobic exercise
C. Weight-bearing exercise
D. Muscle stretching and toning
B. Aerobic exercise
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?
A. CT scan that was performed 6 months earlier
B. Metal hip prosthesis was placed 20 years ago
C. Report of client’s sobriety for the last 5 years
D. Takes metformin for type 2 diabetes mellitus
D. Takes metformin for type 2 diabetes mellitus
A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6h are prescribed. What actions should the nurse include in this client’s plan of care? (Select all that apply)
A. Do not contaminate the insulin aspart so that it is available for IV use
B. Review with the client proper foot care and prevention of injury
C. Teach subcutaneous injection technique, site rotation, and insulin management
D. Coordinate carbohydrate controlled meals at consistent times and intervals.
E. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
F. Fingerstick glucose assessments every 6h with meals
B. Review with client proper foot care and prevention of injury
C. Teach subcutaneous injection technique, site rotation, and insulin management
D. Coordinate carbohydrate controlled meals at consistent times and intervals
F. Fingerstick glucose assessments every 6h with meals
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate attention?
A. A 14yo client with anorexia nervosa who is refusing to eat the evening snack
B. A 16yo client diagnosed with major depression who refuses to participate in group
C. A 17yo client diagnosed with bipolar disorder who is pacing around the lobby
D. An 18yo client with antisocial behavior who is being yelled at by other clients
D. An 18yo client with antisocial behavior who is being yelled at by other clients
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?
A. Obtain the client’s 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids
D. Initiate prescribed intravenous fluids
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose?
A. Bradycardia
B. Tachypnea
C. Hypertension
D. Coughing
A. Bradycardia
Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
A. Upper body muscle strength
B. Balance and posture
C. Risk for disuse syndrome
D. Pressure sore risk
A. Upper body muscle strength
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital
D. Children usually resume their toileting behaviors when they leave the hospital
The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
A. Report any client complaint of pain or discomfort
B. Evaluate the client for sleep disturbances
C. Assess the client for weakness and fatigue
D. Weigh the client and report any weight gain
E. Note and report the client’s food and liquid intake during meals and snacks
A. Report any client complaint of pain or discomfort
D. Weigh the client and report any weight gain
E. Note and report the client’s food and liquid intake during meals and snacks
A young adult visits the client reporting symptoms associated with gastritis. Which information in the client’s history is most important for the nurse to address in the teaching plan?
A. Consumes 10 or more drinks of alcohol every weekend
B. Snacks on foods with very high salt content on a daily basis
C. Exercises vigorously every evening right before going to bed
D. Recently became a vegetarian and eats a lot of high fiber foods
A. Consumes 10 or more drinks of alcohol every weekend
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
A. Auscultate for bowel sounds in all quadrants
B. Ask the client about gastrointestinal pain
C. Monitor the client’s serum electrolyte levels
D. Measure the client’s fluid intake and output
B. Ask the client about gastrointestinal pain
When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client’s history is related to this finding?
A. The second stage of labor lasted 10 minutes
B. She received butorphanol 2mg IVP during labor
C. She is over 35 years of age
D. She is a gravida 6, para 5
D. She is a gravida 6, para 5
When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?
A. Client uses the arm cautiously
B. Red streak tracking the vein
C. A sluggish blood return
D. Spot of dried blood at insertion site
B. Red streaks tracking the vein
An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the nurse implement these interventions? (Highest to lowest priority)
- Send emesis sample to the lab
- Elevate the head of the bed
- Complete focused assessment
- Offer PRN pain medication
When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?
A. History of intermittent claudication
B. A positive Brodie-Trendelenburg test
C. Ankle ulceration and edema
D. A serum cholesterol level of 250mg/dl (6.47mmol/L)
A. History of intermittent claudication
The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endocarditis (IE). What information is most important for the nurse discuss with the parents about the child’s recovery and prevention of IE?
A. Refer the mother to the healthcare provider to discuss infective endocarditis
B. Brush the child’s teeth every day and ensure the child receives regular dental followup
C. Give the child acetaminophen for pain or fever and visit the surgeon for follow-up
D. Monitor the child for regular bowel movements and urine output that exceeds intake
B. Brush the child’s teeth every day and ensure the child receives regular dental followup
An unlicensed assistive personnel (UAP) is assigned to ambulate a client with influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take?
A. send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client
C. Before changing assignments, determine which staff members have fitted particulate filter masks
D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?
A. Only 30% of clients did not attend self-management education sessions.
B. More than 50% of at-risk clients were diagnosed early in their disease process
C. Clients who developed disease complications promptly received rehabilitation
D. Average client scores improved on specific risk factor knowledge tests
C. Clients who developed disease complications promptly received rehabilitation
Then nurse identifies several nursing problems for client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The client’s spouse is the primary caregiver. In planning care, which problem has the highest priority?
A. Impaired bed mobility
B. Caregiver role strain
C. Fluid volume deficit
D. Bowel incontinence
D. Bowel incontinence
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
A. Teach coughing and deep breathing exercises
B. Assess the client’s oral cavity for ulcerations
C. Request thick nectar liquids for the client
D. Monitor the client when using a straw for liquids
A. Teach coughing and deep breathing exercises
An adult client is admitted to the emergency department after falling from the ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement?
A. Review client’s history for use of illicit drugs
B. Explain the reason for using only non-narcotics
C. Assess client’s pupils for their reaction to light
D. Request that the CT scan be done immediately
B. Explain the reason for using only non-narcotics
The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?
A. Monitoring telemetry and cardiac rhythm
B. Assisting client to cough and deep breath
C. Administering narcotics for pain relief
D. Increasing the client’s fluid intake
C. Administering narcotics for pain relief
The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
A. Monitor lying, sitting, and standing blood pressures
B. Provide coaching in relaxation techniques
C. Complete abnormal involuntary movement scale (AIMS)
D. Discontinue all medications immediately
C. Complete abnormal involuntary movement scale (AIMS)
Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?
A. Disrupted surfactant production
B. Metabolic acidosis
C. Aphasia and memory loss
D. Deep sleep or coma
A. Disrupted surfactant production
A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?
A. A change in the sleep-wake cycle
B. Mild sedation
C. Dizziness reported after initial dose
D. Somnambulism
D. Somnambulism
The nurse instructs a client in use of a incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?
A. Auscultate the client’s lungs for adventitious sounds
B. Encourage the client to practice until successful
C. Emphasize the need to inhale slowly into the spirometer
D. Remind the client to cough after using the spirometer
D. Remind the client to cough after using the spirometer
A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. Which action should the nurse implement?
A. Advise the client that lifestyle changes often take several weeks to be effective
B. Encourage the client to exercise everyday to eliminate bedtime wakefulness
C. Ask the client for a description of the exercise schedule that is being followed
D. Determine the amount of weight the client has lost since increasing activity
C. Ask the client for a description of the exercise schedule that is being followed
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics? (Select all that apply)
A. Uses common words with few syllables
B. Printed using a 12-point type font
C. Uses pictures to help illustrate complex ideas
D. Contains a list with definitions of unfamiliar terms
E. Written at a twelfth-grade reading level
A. Uses common words with few syllables
C. Uses pictures to help illustrate complex ideas
D. Contains a list with definitions of unfamiliar terms
The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?
A. Elevate the legs to assess for color changes
B. Provide a heating pad for PRN use
C. Offer cold packs when the pain occurs
D. Suggest dangling the legs when pain occurs
C. Offer cold packs when the pain occurs
The nurse assess a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of the the treatment? (Select all that apply)
A. Functional ability
B. Skin integrity
C. Pain scale
D. Bowel sounds
E. heart sounds
A. Functional ability
B. Skin integrity
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hr. The available solution is Heparin Sodium 25,000 units in 5% Dextrose injection 250mL. The nurse should program the infusion pump to deliver how many mL/hour?
18
When providing client care the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?
A. Past experience with similar problems
B. Relevance to the situation
C. Related personal values
D. Frequency that the problem occurs
B. Relevance to the situation
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider’s attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose
B. Allopurinol
A client with urge incontinence was treated with onabotuilinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client’s plan of care?
A. Provide a bedside commode for immediate use in the client’s room
B. Teach the client techniques for performing intermittent catheterization
C. Explain the need to limit intake of oral fluids to reduce client discomfort
D. Remind the client to practice pelvic floor (Kegel) exercises regularly
D. Remind the client to practice pelvic floor (Kegel) exercises regularly
After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply)
A. Location of the initial IV site
B. Red blood cell count (RBC)
C. Swollen lymph nodes in the groin
D. White blood cell count (WBC)
E. Core body temperature
C. Swollen lymph nodes in the groin
D. White blood cell count (WBC)
E. Core body temperature
The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?
A. Encourage family members to cook meals outdoors and bring the cooked food inside
B. Assess the client’s mucous membranes and report the findings to the healthcare provider
C. Advise the client to replace cooked foods with a variety of different nutritional supplements
D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
A. Encourage family members to cook meals outdoors and bring the cooked food inside
The nurse is wearing personal protective equipment (PPE) while caring for a client. When exiting the room, which PPE should be removed first?
A. Gloves
B. Mask
C. Eyewear
D. Gown
A. Gloves
An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse’s response should be based on what information?
A. The client probably has an organic brain disease and will likely have Alzheimer’s disease within a few years
B. The family needs a social worker to talk to them about how to handle their father when he becomes annoying
C. The daughter is under stress and should be encouraged to think about happier times
D. If the client was compulsive about food when he was younger, the aging process can magnify this
D. If the client was compulsive about food when he was younger, the aging process can magnify this
A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?
A. Glucose
B. Calcium
C. Platelet count
D. White blood cell count
C. Platelet count
The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?
A. The modified checklist for autism in toddlers (M-CHAT)
B. Psychology Systems Questionnaire (PHQ-2)
C. Behavioral Style Questionnaire (BSQ)
D. The Ages and Stages Questionnaire (ASQ)
A. The Modified Checklist for Autism in Toddlers (M-CHAT)
Prior to surgery, written consent must be obtained. Which is the nurse’s legal responsibility with regard to obtaining written consent?
A. Explain the surgical procedure to the client and ask the client to sign the consent form
B. Ask the client or a family member to sign the surgical consent form
C. Determine that the surgical consent form has been signed and is included in the client’s record.
D. Validate the client’s understanding of the surgical procedure to be conducted
C. Determine that the surgical consent form has been signed and is included in the client’s record
A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client’s serum laboratory values requires intervention by the nurse?
A. T3- uptake at 50%
B. Glucose 150 mg/dL
C. Total calcium 5.0 mg/dL
D. Thyroxine 12 mcg/dL
C. Total calcium 5.0 mg/dL
A client in the third trimester of pregnancy reports that she fells some “lumpy places” in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client’s prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere
C. Explain that this normal secretion can be assessed at the next visit
While the nurse is assessing an older client’s fall risk, the client reports living at home alone and never falling. Which action should the nurse take?
A. Inform the client that falls occur more often in the hospital than at home
B. Record a minimal risk for falls, documenting the client’s statement
C. Continue to obtain client data needed to complete the fall risk survey
D. Place the client on a high fall risk protocol because of advanced age
C. Continue to obtain client data needed to complete the fall risk survey
The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
A. Find outlets for more social interaction
B. Practice using muscle relaxation techniques
C. Center attention on positive upbeat music
D. Think about reasons the episodes occur
B. Practice using muscle relaxation techniques
A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
A. Plans to move into the dormitory need to be postponed for at least a semester
B. These are common side effects of the vaccines and will resolve in a few days
C. Immunizations can trigger a relapse of the disease, so get plenty of extra rest
D. these early signs of an infection may require medical treatment with antibiotics
C. Immunizations can trigger a relapse of the disease, so get plenty of extra rest
The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?
A. Arterial blood gasses
B. Breath sounds
C. Oxygen saturation
D. Respiratory rate
A. Arterial blood gasses
An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
A. Prepare the client for an echocardiogram
B. Document in the client’s record
C. Notify the healthcare provider
D. Limit the client’s fluids
B. Document in the client’s record
A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his “right foot is aching”. The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?
A. Encourage discussion of feelings about the loss of his limb
B. Administer a prescription for gabapentin, a neuroleptic agent
C. Tech the client how to wrap the stump with an elastic bandage
D. Offer to assist the client to a quieter location so he can relax
A. Encourage discussion of feelings about the loss of his limb
A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated?
A. Willing to comply with complex drug schedules
B. Maintains an adequate social support system
C. Qualifies for a prescription assistance program
D. States various side effects of retroviral agents
A. Willing to comply with complex drug schedules
The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)
A. Loosen restrictive clothing
B. Insert a bite block
C. Ease the client to the floor
D. Note the duration of the seizure
E. Restrain the client
A. Loosen restrictive clothing
C. Ease the client to the floor
D. Note the duration of the seizure
On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?
A. Which family member has the client’s suicide note
B. What drugs the client used for the suicide attempt
C. When the client last took drugs for bipolar disorder
D. Whether the client over attempted suicide in the past
C. When the client last took drugs for bipolar disorder
The nurse has complete the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
A. A tuna fish sandwich with chips and ice cream
B. A salad with three kinds of lettuce and fruit
C. A peanut butter sandwich with soda and cookies
D. Vegetable soup, crackers, and milk
A. A tuna fish sandwich with chips and ice cream
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?
A. A listing of African-American women who live in the community
B. Morbidity data for breast cancer in women of all races
C. Participation of community leaders in planning the program
D. Technical assistance to produce a video on breast self-examination
C. Participation of community leaders in planning the program
A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement?
A. Suggest the nurse use a 20-gauge needle
B. Instruct the nurse to remove the needle
C. Direct the nurse to change the IV tubing
D. Prompt the nurse to apply povidone to the site
A. Suggest the nurse use a 20-gauge needle
After reviewing the Braden Scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client?
A. A poorly nourished client who requires liquid supplements
B. An older adult who is unable to communicate elimination needs
C. A woman with osteoporosis who is unable to bear weight
D. A older man whose sheets are damp each time he is turned
D. A older man whose sheets are damp each time he is turned
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as a result of this increase in glaucoma surgeries?
A. Decreased prevalence of glaucoma in the population
B. Increased incidence of glaucoma in the population
C. Decreased morbidity in the elderly population
D. Increased mortality in the elderly population
A. Decreased prevalence of glaucoma in the population
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first?
A. Explore client’s readiness to discuss the situation
B. Determine the frequency and type of client’s abuse
C. Report the finding to the police department
D. Discuss treatment options for abusive partners
A. Explore client’s readiness to discuss the situation
A client’s morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?
A. Maintain accurate intake and output
B. Administer prescribed diuretic
C. Weigh client every morning
D. Restrict daily fluid intake to 1500mL
B. Administer prescribed diuretic
The nurse is evaluating the chest drainage system of a client with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse?
A. Rise and fall of water level with respiration
B. Continuous bubbling in the water-seal chamber
C. Total fluid level in water-seal chamber unchanged
D. An average collection of 50 mL/hr drainage
B. Continuous bubbling in the water-seal chamber
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the laboratory value for which medication?
A. Lorazepam
B. Fluoxetine
C. Divalproex
D. Olanzapine
C. Divalproex
A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response?
B. Normal electroencephalogram after drug administration
The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?
A. apply a gait belt around the client’s waist once a standing position has been assumed
B. Place the client’s locked wheelchair on the client’s strong side next to the bed
C. Pull the client into position by reaching from the opposite side of the bed
D. Hold the client at arm’s length while transferring to better distribute the body weight
B. Place the client’s locked wheelchair on the client’s strong side next to the bed
The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound?
A. Stridor
B. Low pitched or coarse crackles
C. High pitched or fine crackles
D. High pitched wheeze
C. High pitched or fine crackles
A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?
A. Observe the appearance of the stool
B. Assess the elasticity of the client’s skin
C. Review the client’s laboratory values
D. Auscultate the client’s bowel sounds
A. Observe the appearance of the stool
A female client with a history of heart failure (HF) arrives at the clinic after what she describes as a very long trip. Following the initial physical assessment and chart review, which priority action should the nurse implement?
A. Administer the prescribed diuretic
B. Give a potassium supplement
C. Reteach medication regimen
D. Auscultate lung and heart sounds
A. Administer the prescribed diuretic
The nurse is preparing a client for discharge who was hospitalized with an acute flare of systemic lupus erythematosus (SLE) symptoms. Which instruction is most important for the nurse to include?
A. Use a walker when weakness occurs
B. Take prescribed cortisone accurately
C. Decrease daily intake of sodium in diet
D. Avoid extreme environmental temperatures
D. Avoid extreme environmental temperatures
A nurse working on an Endocrine Unit should see which client first?
A. An older client with Addison’s disease whose current blood sugar level is 62 mg/dL
B. A client taking corticosteroids who has become disoriented in the last two hours
C. An adolescent male with type 1 diabetes who is arguing about his insulin dose
D. An adult with a blood sugar of 384 mg/dL and a urine output of 350mL in the last hour
B. A client taking corticosteroids who has become disoriented in the last two hours
The nurse assesses a client who has bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client’s right knee is saturated with serosanguineous drainage. What action should the nurse implement?
A. Monitor the client’s current WBC
B. Withhold next scheduled dose of low molecular weight heparin
C. Confirm that the continuous passive motion device is intact
D. Determine if the wound drainage device is functioning correctly
D. Determine if the wound drainage device is functioning correctly
The healthcare provider prescribes cephalexin 125mg/5mL oral suspension for a client who weighs 77 pounds. The recommended safe dose 25mg/kg/24 hours in 4 divided doses. Based on the client’s weight, how many mL should the nurse administer?
9
A middle-aged client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on the client’s age and recent life-threatening crisis, which intervention should the nurse implement?
A. Encourage the client to reflect on personal goals and priorities
B. Allow long periods of uninterrupted rest in order to reduce fatigue
C. Discuss the cause of the accident with the client and his family
D. Provide a routine schedule of activities to facilitate trust
A. Encourage the client to reflect on personal goals and priorities
A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?
A. Encourage the client to seek genetic counseling to determine his risk for mental illness
B. Inform the client that his mother’s schizophrenia has affected his psychological development
C. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist
D. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed
D. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed
Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider?
A. Serum sodium 142mEq/L
B. Serum potassium 3.9mEq/L
C. Serum glucose 62 mg/dL
D. Blood urea nitrogen 18 mg/dL
C. Serum glucose 62 mg/dL
When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply)
A. Fresh vegetables with mayonnaise dip
B. Fresh turkey slices and berries
C. Chicken bouillon soup and toast
D. Soda crackers and peanut butter
E. Raw unsalted almonds and apples
B. Fresh turkey slices and berries
C. Chicken bouillon soup and toast
E. Raw unsalted almonds and apples
A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every 12 hours. When the client requests an afternoon snack, which dietary choice should the nurse provide?
A. Cinnamon applesauce
B. Vanilla-flavored yogurt
C. Calcium-fortified juice
D. Low-fat chocolate milk
A. Cinnamon applesauce
When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client’s plan of care?
A. Assess bilateral breath sounds
B. Review client’s daily medications
C. Initiate neurological monitoring every 2 hours
D. Palpate suprapubic region for urinary retention
C. Initiate neurological monitoring every 2 hours
An older client’s daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter stated that her mother’s behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take?
A. Encourage increased intake of high protein foods
B. Instruct the daughter to check her mother’s temperature
C. Review the client’s current food and medication allergies
D. Ask if the mother is experiencing any pain with urination
E. Determine if the mother has recently experienced a fall.
A. Encourage increased intake of high protein foods
B. Instruct the daughter to check her mother’s temperature
D. Ask if the mother is experiencing any pain with urination
The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give this nurse?
A. Assist cardiac nurses with their assignments
B. Monitor the central telemetry
C. Perform the admission of a new client
D. Transfer a client to another unit
A. Assist cardiac nurses with their assignments
A client with Type 1 diabetes mellitus and a large draining ulcer of the right foot is admitted with a suspected Staphylococcus aureus infection. Which interventions should the nurse implement? (Select all that apply)
A. Monitor the client’s white blood cell count
B. Explain the purpose of a low bacteria diet
C. Send wound drainage for culture and sensitivity
D. Institute contact precautions for staff and visitors
E. Use standard precautions and wear a mask
A. Monitor the client’s white blood cell count
C. Send wound drainage for culture and sensitivity
D. Institute contact precautions for staff and visitors
The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding?
A. An audible voice when client is trying to communicate
B. High pressure alarm sounds when client is coughing
C. Restrained and restless with a low volume alarm sounding
D. Diminished breath sounds in the right posterior base
C. Restrained and restless with a low volume alarm sounding
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse?
A. Instruct the client that these mild symptoms can generally be controlled with changes in his diet
B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms
C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer
D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food
C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer
The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension?
A. Grilled steak, baked potato with sour cream, green beans, coffee, and raisin cream pie
B. Baked pork chops, applesauce, corn on the cob, 1% milk, and key-lime pie
C. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie
D. Beef stir fry, fried rice, egg drop soup, diet soda, and pumpkin pie
B. Baked pork chops, applesauce, corn on the cob, 1% milk, and key-lime pie
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider?
A. Volume of each voiding is more than 300mL
B. Serum potassium that is elevated
C. Relief of flank pain that radiated into the groin
D. Hematuria that is beginning to turn pink
D. Hematuria that is beginning to turn pink
Three days after initiating parenteral fluids for a newborn with a ventricular septal defect (VSD), the nurse assesses an increase in heart rate and blood pressure. Which intervention is most important for the nurse to implement?
A. View the graph of daily weights
B. Restrict intake of oral fluids
C. Assess bilateral lung sounds
D. Decrease IV flow rate
B. Restrict intake of oral fluids
During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?
A. History of suicide attempts
B. Feelings of disorientation
C. Undiagnosed social anxiety symptoms (SAD)
D. Family history of schizophrenia
A. History of suicide attempts
The healthcare provider prescribes penicillin G benzathine 2,400,000 units intramuscularly for a client who has a postoperative wound infection. The prefilled syringe is labeled, penicillin G benzathine 1,200,000 units/2mL. How many mL should the nurse administer to this client?
4mL
A client who experienced a cerebrovascular accident (CVA) is aphasic and has left sided paralysis. Which nurse should be responsible for coordinating the progression of this client’s care?
A. Nurse case manager
B. Adult nurse practitioner
C. Neurology unit supervisor
D. Risk management nurse
B. Adult nurse practitioner
A client who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse?
Lethargy
A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should the nurse include in the plan of care?
A. Sleeps at least 6 hours per night
B. Consumes 3 meals and 1500 mL of fluid per day
C. Engages in one client to client interaction daily
D. Attends one group activity per day
D. Attends one group activity per day
A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL
D. Serum potassium of 3.0 mg/dL
A male client approaches the nurse with an angry expression on his face and raises his voice, saying “My roommate is the most selfish, self-centered, angry person I have ever met and if he loses his temper one more time with me, I am going to punch him out!” The nurse recognizes that the client is using which defense mechanism?
A. Splitting
B. Projection
C. Rationalization
D. Denial
B. Projection
The nurse is teaching the client about home care after surgery for an ileal conduit placement. When reviewing the information, which statement should the nurse recognize as needing additional education?
A. report presence of mucus in the urine
B. Empty pouch when it is half full
C. Look at the stoma when replacing appliance
D. Anticipate shrinking of the stoma
B. Empty pouch when it is half full
A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse?
A. One inch bleeding laceration on the chin of crying 5 year old
B. Low grade fever, headache and malaise for the past 72 hours
C. Chest discomfort one hour after consuming a large, spicy meal
D. Unable to bear weight on the left food, with swelling and bruising
C. Chest discomfort one hour after consuming a large, spicy meal
When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm, but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?
A. Analyze the cardiac rhythm in another lead
B. Obtain a 12-lead electrocardiogram
C. Observe for swelling at the fracture site
D. Begin chest compressions at 100/minute
D. Begin chest compressions at 100/minute
The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?
A. Change the dressing using a compression bandage
B. Test the fluid on the dressing for glucose
C. Document the findings in the electronic medical record
D. Mark the drainage area with a pen and continue to monitor
B. Test the fluid on the dressing for glucose
After administering a 12 ounce can of nutritional supplement, 3 teaspoons of medication, and 120 mL of water, the nurse should document the client’s fluid intake as how many mL?
495
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicates the client understands how to maintain balance safely? (Select all that apply)
A. Brings a heavy can close to body before lifting
B. Leans forward to pull on a pan from a high shelf
C. Locks knees while preparing food on the counter
D. Bends from the waist to pick trash off the floor
E. Widens stance while working near the sink
C. Locks knees while preparing food on the counter
D. Bends from the waist to pick trash off the floor
A client with rheumatoid arthritis (RA) starts a new prescription for etanercept subcutaneously once weekly. The nurse should emphasize the importance of reporting which problem to the healthcare provider?
A. Joint stiffness
B. Persistent fever
C. Headache
D. Increased hunger and thirst
A. Joint stiffness
A client with multiple burn injuries is being treated in the burn trauma unit just hours after the injuries occurred. The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes. Which intervention is most important for the nurse to implement?
A. Dress each wound separately
B. Assign equipment to this one client
C. Utilize reverse isolation protocol
D. Use gown, mask, and gloves with dressing changes
D. Use gown, mask, and gloves with dressing changes
A client with chronic kidney disease has an arteriovenous fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
A. Assessment of a bruit on the left forearm
B. Auscultation of a thrill on the left forearm
C. The left radial pulse is 2+ bounding.
B. Auscultation of a thrill on the left forearm
A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement?
A. Check femoral site for hematoma formation
B. Stimulate the client to take deep breaths
C. Evaluate the integrity of the IV insertion site
D. Assess distal lower extremity capillary refill
B. Stimulate the client to take deep breaths
The nurse is caring for client with flail chest secondary to 3 right rib fractures after sustaining a fall from a ladder. The client is anxious, but stable with an oxygen saturation of (SpO2) 93%. Which action should the nurse take?
A. Splint affected side
B. Insert nasal airway
C. Coach through taking deep breaths
D. Apply a non-rebreather mask
A. Splint affected side
The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which actions should the nurse implement? (Select all that apply)
A. Teach care of ostomy to care provider
B. Assess the client for self care ability
C. Provide pain medication instructions
D. Request a home safety inspection
E. Call home care agency to set up oxygen
A. Teach care of ostomy to care provider
B. Assess the client for self care ability
C. Provide pain medication instructions
The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia. The client reports having sex with someone who had many partners. Which response should the nurse provide?
A. Inform that follow-up may end after the treatment is finished
B. Reassure that complications will not occur if the infection is treated
C. Notify that persons with STIs are reported to local health departments
D. Explain how the infection is transmitted and the health risks involved
A. Inform that follow-up may end after the treatment is finished.
In evaluating the effectiveness of a postoperative client’s intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?
A. Monitor the amount of drainage from the client’s incision
B. Observe both lower extremities for redness and swelling
C. Evaluate the client’s ability to use an incentive spirometer
D. Palpate all peripheral pulse points for volume and strength
B. Observe both lower extremities for redness and swelling
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
A. Review medical records to obtain pain tolerance expectations
B. Attempt to obtain a self-report of pain level from the client
C. Provide the first medication prescribed for pain management
D. Wait until the client is awake before providing pain management
B. Attempt to obtain a self-report of pain level from the client
The nurse assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client states the left knee is swollen and extremely pain to touch. Which instruction should the nurse include in the discharge teaching?
A. Decrease consumption of red meat and most seafood
B. Substitute natural fruit juices for carbonated drinks
C. Limit use of mobility equipment to avoid muscle atrophy
D. Use electric heating pad when pain is at its worse
A. Decrease consumption of red meat and most seafood
The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3 year old son for wetting his pants. What initial action should the nurse take?
A. Provide disposable training pants while calming the mother
B. Refer the mother to a community parent education program
C. Inform the mother that toilet training is slower for boys
D. Suggest that the mother consult a pediatric nephrologist
C. Inform the mother that toilet training is slower for boys
The nurse is caring for a client with heart failure. Which method is used in computing the cardiac index to measure how the client’s heart is functioning?
A. Mean arterial pressure minus right atrial pressure
B. Cardiac output divided by body surface area
C. Stroke volume divided by end diastolic volume
D. Stroke volume multiplied by heart rate
B. Cardiac output divided by body surface area
Two days prior to discharge from the rehabilitation facility, the nurse is teaching a client who is recovering from Guillain-Barre syndrome about home care. Which actions should the nurse include when providing discharge teaching to the client and spouse? (Select all that apply)
A. Review safe transfer strategies
B. Develop a nutritional plan
C. Help identify community support
D. Initiate a rigorous exercise routine
E. Provide cooking instructions
A. Review safe transfer strategies
B. Develop a nutritional plan
C. Help identify community support
A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?
A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
B. Move the client to a private room, keep the door closed, and initiate droplet precautions.
C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus
D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
An older adult client with systemic inflammatory response syndrome (SIRS) has a temperature of 101.8F, heart rate of 110 beats/minute, and respiratory rate of 24 breaths/minute. Which additional finding is most important to report to the healthcare provider?
A. Capillary glucose reading of 110 mg/dL
B. Serum creatinine of 2.0 mg/dL
C. Blood pressure of 130/88 mmHg
D. Hemoglobin of 12 g/dL
B. Serum creatinine of 2.0 mg/dL
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?
A. Evaluate a client’s mobility progress toward the plan of care
B. Assess for side effects of administered pain medications
C. Turn and reposition a client with a total hip replacement
D. Monitor an intravenous infusion rate on an established schedule
C. Turn and reposition a client with a total hip replacement
After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client’s serum creatinine is 0.3 mg/dL. Which action should the nurse implement?
A. Evaluate the client’s serum BUN level
B. Initiate the urine collection as prescribed
C. Notify the healthcare provider of the results
D. Assess the client for signs of hypokalemia
C. Notify the healthcare provider of the results
The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?
A. The client’s skin on the lower legs will be intact at the next clinic visit
B. The client will express acceptance of their newly diagnosed health status
C. The client’s blood pressure readings will be less than 160/90 mmHg
D. The nurse will encourage the client to walk thirty minutes every day
C. The client’s blood pressure readings will be less than 160/90 mmHg
The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?
A. Increase activity and exercise gradually, as tolerated
B. Limit intake of fatty foods for one month after surgery
C. Avoid crowds for first two months after surgery
D. Notify the healthcare provider if edema occurs
C. Avoid crowds for first two months after surgery
What might the nurse suggest to a client with fibrocystic breasts in an attempt to help relieve her symptoms?
A. “Eliminate caffeine from your diet”
B. “Avoid vigorous physical exercise immediately after your menstrual periods”
C. “Eat a low-carbohydrate, high-protein diet”
D. “Increase high-calcium foods in your diet”
D. “Increase high-calcium foods in your diet”
When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply)
A. Cheese
B. Tea
C. Lentils
D. Whole grain breads
E. Potato soup
B. Tea
C. Lentils
E. Potato soup
The mother of a 2 day old infant girl expresses concern about a “flea bite” type rash on her daughter’s body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?
A. This is a common newborn rash that will resolve after several days
B. The rash is due to distended oil glands that will resolve in a few weeks
C. The healthcare provider is being notified about the rash
D. This rash is characteristic of a medication reaction
A. This is a common newborn rash that will resolve after several days
A client is diagnosed with Meniere’s disease. Which problem should the nurse identify as most important in the plan of care?
A. Risk for ineffective self-health management related to deficient knowledge
B. Ineffective coping related to personal vulnerability
C. Risk for injury related to vertigo
D. Anxiety related to disruption of lifestyle
C. Risk for injury related to vertigo.
The nurse should withhold which medication if the client’s serum potassium level is 6.2 mEq/L?
A. Metolazone
B. Furosemide
C. Spironolactone
D. Hydrochlorothiazide
C. Spironolactone
A female client presents in the emergency department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department?
A. Has she taken a bath since the rape occurred?