A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder.
A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment?
Tell me about your siblings
Tell me what kind of music you like c) Tell me how often do you drink alcohol
d) Tell me about your school schedule
A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene?
Holding the newborn in an en face position
Asking the father to change the newborn’s diaper
Requesting the nurse take the newborn nursery so she can rest d) Viewing the newborn’s actions to be uncooperative
A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the medication is effective?
Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
Decreased blood pressure
Absence of seizures
Decrease inflammation
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?
Contact provider if the cord still turns black (it’s going to turn black)
Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days)
A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?
Shivering b) Oliguria
Bradypnea
Constricted pupils
A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identify as the priority?
A client that has massive head trauma
A client has full thickness burns to face and trunk c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity
A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first?
A client who has illeal conduit and mucus in the pouch
Client pleasant arteriovenous additional vibration palpated
A client whose chronic kidney disease with cloudy diasylate outflow
A client was transurethral resection of the prostate with a red tinged urine in the bag
A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention?
Place’s cardiac monitoring
Monitor the clients oxygen saturation level c) Provide standby assist with the client from bed
d) Encourage foods high in potassium
A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect?
Feta hypoxia
Abrupto placentae
Post maturity
Head Compression
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis?
glomerular filtration rate of 14 mL/ minute
BUN 16 mg/DL
serum magnesium 1.8 mg mg/dl
Serum phosphorus 4.0 mg/dL
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take?
Placed infant under radiant warmer
Move the probe site every 3 hours
Heat the skin one minute prior to placing the program
Placed a sensor on the index finger
A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first?
Client placed in restraints to the aggressive behavior
A new limited client pleasures history of 4.5 kg weight loss in the past two months
Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
Applied he’ll be receiving his first ECT treatment today
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor?
Hypnosis focuses on the biofeedback as a relaxation technique
Hypnosis promotes increased control of her pain perception during contractions
Hypnosis uses therapeutic touch to reduce anxiety during labor
Hypnosis provides instruction to minimize pain
A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone you dislike)
I steal things because it’s the only way I can keep my mind off my bad marriage
I can’t believe I was accused of something I didn’t do
I don’t want talk about my feelings right now. We will talk more next time
I think that people just you’re just lazy and should earn money honestly
A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate. Which of the following should the nurse identify as a contraindication to medication?
Glaucoma
Hypertension
Polycythemia
Migraine headaches
16) ?
The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care?
Draw a troponin level every four hours
Performance EKG every 12 hours
Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitation consult
A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider?
WBC 3,000/mm3
Hemoglobin 14 g/dl
Platelet 250,000/mm3
aPTT 30 seconds
Home health nurse is carefully planned for Alzheimer’s disease. To the following action should the nurse include in the plan of care
Place a daily calendar in the kitchen
Replace button clothing with zippered items
Replace the carpet with hardwood floors
Create variation in daily routine
Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first?
The client was cystic fibrosis and has a thick productive clock and reports thirst
Client who has gastroenteritis and is lethargic and confused
The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over deal
The client was sick of signing it reports pain 15 minutes after receiving oral analgesic
A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?
Decrease taking vitamins and supplements to every other day
Eat 15 g of fiber per day
Consume 48 ounces of water each day (need at least 64 oz)
Drink hot water with lemon juice each morning when you wake up
22) ?
A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply
I can’t change my instructions once a minute
My doctor will need to approve my advance directives
I need an attorney to witness my signature on the advance directives d) I have the right to refuse treatment
e) My health care proxy can make medical decisions for me
A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output?
The chest
Standing
Supine
Left lateral
A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP?
Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry
Client who has awoken following a bronchoscopy and requests a drink
Client who had a myocardial infarction 3 days ago reports chest discomfort
Client who had a cerebrovascular accident two days ago and needs help toileting
Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with
clozapine. Which of the following is the highest priority for the client to report to the provider?
Constipation
blurred vision
Fever
Dry Mouth
A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention?
Providing a high protein snack
Assisting the child to reposition
Placing weights as a child’s bed
Massaging pressure points-causes skin breakdown
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take?
Determine if the AP is qualified to perform the test.
Help the AP performed the blood glucose test
Assign the AP to ask the client is taking his diabetic medication today
Have AP check the medical record for prior blood glucose test results
A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following?
Alzheimer’s disease
Schizophrenia
Substance intoxication
Depression
A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are associated with this diagnosis? Select all that apply
splenomegaly
Koplik spots (this is associated with measles)
Malaise
Vertigo e) Sore throat
Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first?
Apply skin preparation to wound edges.
Normal saline
Don sterile gloves d) Determine pain level
A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
Drainage fluid is greenish-yellow
aspirate pH of 3 c) Abdominal rigidity
d) air bubbles noted in the NG tube
A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take?
Piggyback 0.9 sodium chloride with TPN solution b) Check for an allergy to eggs
Discuss the TPS solution for 12 hours
Monitor for hypoglycemia
A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?)
Systemic analgesic effect
increase in your metabolism c) Decreased capillary permeability
d) Vasodilation
Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to
Perform weight bearing exercises
Avoid crossing the legs beyond the midline
Avoid sitting in one position for prolonged periods
Split affected area
A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority?
The client has surgical hypoparathyroidism and positive Trousseau’s sign
A client who was Clostridium difficile with acute diarrhea
A client who is acute kidney injury and urine with a low specific gravity
The client who has oral cancer and reports a sore on his gums
Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate?
Call the provider to clients respiratory rate is less 18/min
Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr
Give the client enalapril 2.5 mg PO twice daily
Call the provider if the clients pulse rate is less than 80/min
A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?
I will be able starting this medication with feel better
I can expect to urinate frequently while on this medication
I understand I may experience difficulty sleeping on this medication
I should decrease my sodium intake while on this medication
A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?”
Offer to speak to the client’s husband regarding his abuse behavior. b) Help the client to recognize the signs of escalation of abuse behavior
Assist the client to identify personal behaviors that trigger abusive behavior
Assist the client to Reports abusive behavior to the proper authority
A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate?
Why do you think your life is not worth it anymore? b) Do you have a plan to end your life?
I need to know what you mean my misery
You can trust me and tell me what you’re thinking
A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?
Decreased level consciousness
Unable to identify common objects c) Poor problem solving ability
d) Preoccupation was somatic disturbances
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take? There are 3 tabs that contain separate categories of data.
Position the client with the affected extremity lower than the heart
Administration of acetaminophen
Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion
Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?
Expel air bubble at the top of the prefilled syringe
Massage the injection site to evenly distribute the medication c) Inject the medication the lateral abdominal wall
d) Administer an NSAID for injection site discomfort
Nurses caring for four clients. Which of the following client data should the nurse report to the provider?
A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hour following surgery
Client who is 4 hrs postoperative and has a heart rate of 98 per minute
The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?
Promethazine b) Hydromorphone
Ketorolac
Amitriptyline
A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care?
Live with the clients fluid intake to 1500 mL per day
Massage place affected extremity to relieve pain
Apply cold packs of clients affected extremity
Elevate the client’s affected extremity when in bed
A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take?
Discontinue oxytocin infusion
Increased oxytocin infusion
Decreased oxytocin infusion
Maintain oxytocin infusion
A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?
Have your membranes ruptured?
How far apart are your contractions? c) Do you have any active lesions?
d) Are you positive for beta strap?
Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should the nurse include?
Take with meals
Take at bedtime
Take with a glass of milk
Take with a glass of orange juice
Four clients present to the emergency department. The nurse should plan to see which of the following clients first?
A 6 year old client whose left shoulder is dislocated
A 26 year old client for sickle cell disease and a severe joint pain
A 76 year old client was confused, febrile and has foul smelling urine – uti
A 50- year old client who has slurred speech, is disoriented, and reports a headache – stroke
A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
Leavened bread maybe eaten during Passover.
Shellfish is commonly consumed in the diet. c) Meat and dairy products are eaten separately.
d) Fasting from meat occurs during Hanukkah.
52) ?
A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply
Apply direct pressure to bleeding wounds
Clean rest last rations and abrasions with hydrogen peroxide c) Cover wounds with a sterile dressing
d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccination.
The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation?
Sodium 138 b) Creatinine 1.8
Hemoglobin 15
Potassium 4.2
A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching?
I understand the methadone tends to slow my breathing
I understand the methadone may cause me to have difficulty sleeping
I will avoid alcohol while I’m taking this medication
I’ll change positions gradually especially from lying down to standing
Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation?
Premature infant with a poor suck reflex and failure to thrive
An older adults who has difficulty taking in fluids
Adolescent who anorexia who is cachectic
A middle aged adults was gastroesophageal reflux disease
A nurse is caring for a group of clients. Which of the following client should nurse assess first?
A client whose benign prostatic hyperplasia and is unable to urinate
The client was heart failure and report shortness of breath while ambulating
A client who is open cholecystectomy and has green drainage from the T-tube
A client whose abdominal pain and is vomiting coffee ground emesis
A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure?
Atorvastatin
Digoxin
Nifedipine d) Metformin
The nurses assessing client with posttraumatic stress disorder. Which of the following findings to the nurse expect to find?
Dependence on family and friends
Loss of interest in usual activities
Ritualistic behavior
Passive aggressive behavior
A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care?
Give the client several choices when scheduling activities.
Confront the client regarding unacceptable behavior
Maintain Nutritional requirements by offering finger foods
Stimulate the client by leaving the television on throughout the day
A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first?
A client who has begun to demonstrate catatonic behavior
The client was compulsive behavior and is frequently drinking from the water fountain c) Client was having auditory hallucinations is becoming agitated
d) A client was making sexual comments to clients of the opposite sex
A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first?
Instill erythromycin ophthalmic ointment and the newborn’s eyes.
Place identification bracelets on the newborn.
Weigh the newborn.
Dry the newborn
A nurse receives report on a group of clients. Which of the following client should the nurse attend to first?
A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula
A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10
The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL
A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid
A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor?
The client reports the urge to push b) The cervix is dilated 2 cm
Contractions are 2 to 3 minutes apart
The client reports nausea and vomiting
The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned?
An AP is to calculate intake and output every two hours for client in acute renal failure.
An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy
A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident.
A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention?
pruiritus under the cast
Localized stabbing pain upon movement c) paresthesia of the distal extremity
d) Edema present when leg is in the dependent position
The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action? Click on the links of this below for additional client information
Offer the child a cup of chicken broth.
Encourage the child’s intake of gelatin. c) Administer oral rehydration solutions.
d) Institute a banana, Rice, applesauce, and toast diet.
The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication?
Serum chloride b) Uric acid level
Serum albumin
Magnesium level
A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion?
Ventricular asystole
Third-degree AV block c) Atrial fibrillation
d) Ventricular fibrillation
Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions?
Scarlet fever b) Herpes simplex
Varicella
Streptococcal pharyngitis
A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately?
The clinic experiences coughing and wheezing after eating.
The client reports abdominal pain at a five on a scale of 0 to 10.
The client experience is a drop in oxygen saturation to 91% while eating.
The client reports a burning sensation in epigastric area.
A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP?
Applying condom catheter for client for spinal cord injury
Administrative oral fluids to client was dysphasia
Documenting the report of pain from client who is postoperative
Reviewing active range of motion exercises with a client who is had a stroke
A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC?
Candida albicans
Herpes simplex virus 2
staphylococcus aureus d) Lyme disease
The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse?
A pain score 7 on a scale of 0 to 10 b) Shortness of breath
New onset of a new enuresis
Priapism
Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse?
Glascow scale score a 15
Blood drainage on initial dressing measuring 3 cm
Report of dry mouth
Urinary output greater than fluid intake
A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client
Flexes elbows at 30 degrees when using the handgrips
Maintains 3 to 4 finger width between the crutch pad and axilla
Places the crutches 6 inches in front and side of each foot when standing.
Pushes up from a chair with crutches on the unaffected side.
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?
Use a designated stethoscope when caring for the toddler.
Wear an N95 respiratory mask while caring for the toddler.
Remove the disposable gown after leaving the toddler’s room
Place the toddler in a room with negative air pressure.
A nurse is admitting to a client to emergency department and initiates continuous cardiac monitoring. Which of the following ECG with strips indicates sinus tachycardia?
b)
A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the plan of care?
Massage lower extremities daily to prevent DVT
Limit intake of Food high in calcium to prevent renal calculi.
Encourage client to lie supine prevent constipation.
Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.
A nurse discovers that the wrong dosage of medication was given to client. When determining what action to take your should recognize that which of the following ethical principles should be applied?
Utility
Paternalism c) Veracity
d) Fidelity
81) ?
A nurse is review in the prescription for doxazosin with a client. Which of the following should be included in the teaching?
Decrease caloric intake to reduce weight gain.
Increased dietary fiber to prevent constipation.
Rise slowly when sitting up from bed.
Take this medication each morning.
Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching?
Exercising an hour before bedtime
Take a short nap today
Keep bedroom cool at night
Consume a high carbohydrate snack at bedtime.
A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions is appropriate?
Wear a face shield prior into entering the room.
Place the client private room.
Place the client in a negative pressure room.
Use alcohol based hand rub following client care.
A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following intervention should the nurse including the plan of care?
Perform active range of motion exercises.
Perform neurological checks every 4 hours.
Suction the airway frequently.
Maintain the head at a midline position.
The nurse is assessing a client is receiving radiation therapy. Which of the following findings should the nurse expect?
White blood cell count at 12,500 mm3
Excessive salivation
c) +3 pitting edema
d) Platelets 95,000 mm3
A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medications is contraindicated?
Methylergonovine.
Misoprostol
Dinoprostone
Oxytocin
A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect to find?
Shortness of breath
Rebound tenderness c) Atypical chest pain
d) Vomiting blood
A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action?
Ensure eye shield is covering the eyes.
Apply lotion to expose skin.
Offer glucose water between feedings.
Discontinue breast-feeding during treatment.
This is assessing clients as had a long arm cast. Which of the following findings of the dress moderate and when assessing for acute compartment syndrome?
Shortness of breath
Petechiae
Change in mental status d) Edema
I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?
Placed the client in a prone proposition.
Implement Positive pressure ventilation.
Perform nasopharyngeal suctioning. d) administer flumazenil
A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actions should the nurse take first?
Report the AP’s behavior to the supervisor.
Completed instant report regarding the Aps conversation.
Provide the AP with written documentation regarding client confidentiality d) Tell the AP to discontinue their conversation
A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following?
testicular Cancer
Obesity
Stroke
Melanoma
A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following prescription is given by the provider should the nurse clarify?
Over the fact that extremities and two pillows.
Apply heat to affect extremity for 45 minutes on the 45 is off.
wrap the affected extremity with a compression dressing.
Assess the affected extremity for sensation movement impulse every four hours
A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the following food selections indicates that client understands teaching?
a) A sandwich and milkshake b) Rice with black beans
Cottage cheese and tuna lettuce
Three egg omelette with low-sodium ham
A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?
a) Remove dirty linens from the room after double bagging. b) Wear a dosimeter film badge while in the client’s room
Limit each of the clients is yours to one hour per day.
Ensure family members remain at least 3 feet from the client.
A nurses for Caring for four clients. Which of the following client should the nurse care for first?
A client to receive a chemotherapy treatment or first national
A client who has an appendectomy to these don’t has diminished all sounds c) A client is hypothyroidism and his stuporous
d) A client who is a burn requiring a sterile dressing change
The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care?
Initiate droplet precautions for the client
Assisted client to supine position
Performing Glasgow coma scale every 24 hrs
Recommend prophylactic acyclovir there for the clients family.
Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that the teaching has been effective when the client states.
a) I want sure that my medications are enteric coated b) My stoma will drain liquid fluid continuously
I will change my pump system every two weeks
My stoma size will stay the same even after healed
A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to use in combination oral
contraceptives?
thyroid disease
Allergy to penicillin c) impaired liver function
d) abnormal blood glucose
The nurses providing teaching to a client who has mild persistent asthma has been prescribed
montelukast. Which of the following statements to the nursing put in teaching?
This medication can be used to help you when have an acute asthma attack
This medication should be taken before exercise and physical activity
This medication can be taken for 10 days and then gradually discontinued
This medication helps decrease swelling and mucus production
I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first?
A client who is receiving warfarin and has and INR of 3.3
A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL
A client who had a NG tube inserted 6 hr ago and has abdominal distention
A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat
A nurse is assessing a client who has pericarditis. Which of the following findings is priority
Paradoxical pulse pg. 389 under complications
dependent edema
Pericardial friction rub
Substernal chest pain
A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching?
Hydrogen peroxide
Chlorhexidine
Isopropyl alcohol
Chlorine bleach
*A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take?
instruct the client to lift her chin when swallowing
discourage the client from coughing during feedings
Sit at or below the clients eye level during feedings.
Talk with the client during her feeding.
A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a) Assault
Battery
Malpractice
Negligence
A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following?
Re-Evaluate priorities halfway through the shift
Delegate changing sterile dressing for licensed practical nurse
Groups activities for the Same client d) Works on several tasks simultaneously
A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority finding?
Feeling flushed and warm
Abdominal fullness c) Swollen lips
d) Metallic taste in mouth
A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate?
Just the flow rate of the clients oxygen tank
Collecting urine sample
Measuring the clients pain level
Monitoring blood glucose levels
A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure?
a) Systolic presssure subtracted by diastolic pressure (132 – 40) = 92
A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report?
a) A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump has malfunctioned
A client who requires insertion of NG tube due to a bowel obstruction
A client who is absent bell sounds following a gastrectomy
A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor?
Fasting blood glucose
Carbohydrate intake
Hematocrit
Weight
The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse?
I can wear support bra
I will play cold compression my breasts
I will manually express breastmilk
I can take a mild analgesic
A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?
Blood glucose of 150 mg/dL
Urine output of 20 mL per hour
Systolic blood pressure at 140 mm Hg
BUN 20 mg/dL
The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following findings are indicative of cold stress?
a) Respiratory rate of 60 per minute b) Jitteriness of the hands
Diaphoretic
Bounding peripheral pulses in all extremities
A nurse is planning care for four clients. Which of the following clients is the highest priority?
A client who is dry, black eschar on the heel
A client who is wearing an arm cast and reports numb fingers
The client was reddened skin area with blanching around the coccyx
The client who has frequent incontinence
A nurse is caring for a male adolescent client who has heart failure. Based on the client’s chart finds. Which of the following actions should the nurse plan to take?
Withholds spiranolactone
Administer ferrous sulfate
Administer furosemide
Withhold digoxin (0.8-2.0)
The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding?
Confusion (hypoglycemia)
Thirst
Diaphoresis (hypoglycemia)
Shakiness (hypoglycemia)
A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication?
Eggs
Milk
Shrimp
Peanuts
A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this finding which of the following in the client’s chart?
Echolalia
Associative looseness
Neologisms
Concrete thinking
A nurse caring for a client who is receiving total parental nutrition. Which of the following assessment findings required immediate intervention by the nurse?
prealbumin level of 20 mg/dL b. Weight increase of two kg/day
Temperature of 37.6°C
Blood glucose level of 120 mg/dL
A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been treated for myocardial function. The following is an expected finding for the client?
Troponin 1 (TNI) 8 ng/ml
Brain natriuretic peptide (BNP) 10 ng/L
Alanine aminotransferase (ALT 45 unit/L
High density lipoprotein (HDL) 75 mg/dl
A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?
paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg
HCO2 level of 25 mEq/L
pH level of 7.37
A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care?
Administer disulfiram.
Provide frequent orientation to time and place.
Engage the client in group therapy.
Perform gastric lavage.
A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots” can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.)
A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use?
Ventrogluteal
Dorsogluteal
Vastus lateralis
Rectus femoris
A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI?
Wearing underwear with a cotton crotch
Wiping from front to back
Using perfumed toilet paper
Urinating immediately after intercourse
A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching?
“I will take my morning pills with food or milk.”
“I will weigh myself every day.”
“I will notify the nurse if I have muscle cramps.” d. “I will limit my intake of fish.”
A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client
conditions is a contraindication to this medication? a. hepatits C
peptic ulcer disease
bronchitis
chrohn’s disease
A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care?
Encourage a diet high in calcium.
Provide a diet high in potassium.
Ensure increased fluid intake.
Restrict protein intake to the RDA.
A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first?
Take vital signs.
Assess lochia.
Massage the fundus.
Give oxytocin IV bolus.
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform
Give 100 mL of water with every feeding.
Obtain gastric residuals every 24 hr.
Position the head of bed at 30 degrees during feeding.
Mix the clients medications with the tube feedings.
A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective?
Skin turgor displays tenting b. Flat anterior fontanel
Cool, mottled skin
hyperpnea
A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start
radiation therapy. Which of the following should the nurse include in the teaching?
Remove dye markings after each radiation treatment.
Apply a warm compress to the irradiated site.
Wear clothing over the area of radiation treatment.
Use a washcloth to bathe the treatment area.
A nurse in a provider’s office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide
Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective.”
“Take your iron medication with fluids other than coffee or tea.”
“It is important to take your iron medication on a full stomach.”
“If you miss a dose one day, take two doses the next day.”
175 A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess
A client who had a hip arthroplasty reports pain and erythema in his calf
A client who has anorexia and peripheral edema
A client who has Addison’s disease with a blood glucose level of 75 mg/dL
A client who had a barium enema 2 days ago and reports constipation
A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer?
Albuterol sulfate
Hydromorphone
Diphenhydramine
Amitriptyline
A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take?
Ask the assistive personnel to assist the client in signing consent for treatment
Ask the child to interpret for the client.
Ascertain what language the client speaks and get an interpreter.
Try to find an adult relative to help the client communicate.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
Position the client supine.
Prepare an IV bolus of dextrose 5% in water c. Administer calcium gluconate IV.
d. Administer methylergonovine IM.
A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the clients last period was October. What is the expected delivery date? (Provide the date using four numerals, the first two for the month and the second two for the day. For example, January 2 0102)
a. 0711 (July 7, 2011)
Formula: +1 year, -3 months, +7 days
A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first?
A client who is scheduled for chemotherapy and has a hemoglobin of 9
A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP) and has small blood clots in the urinary catheter
A client who is receiving a blood transfusion and reports low-back pain
A client who has a new colostomy with a reddish-pink stoma
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