All Clients Need (0001-0200)

Question 1

A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the nursing assistant to look for and report which of the following symptoms?

Answer 1

Tarry stools.

Question 2

A nurse is assessing a 10-year-old girl. The girl’s mother informs the nurse that she’s concerned about her daughter’s breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response?

Answer 2

The changes in your daughter’s breasts are the first signs of puberty.

Question 3

A 1-year-old child is admitted to the hospital with sickle cell crisis. Which of the following will be a part of the child’s plan of care?

Answer 3

I.V. fluid therapy.

Question 4

A mother tells the nurse that her 4-year-old boy has developed some strange eating habits including not finishing meals and eating the same food for several days in a row. She would like to develop a plan to correct this situation. When developing such a plan, which of the following should the nurse and mother consider?

Answer 4

Allowing him to make some decisions about the foods he eats.

Question 5

When obtaining a client’s history, the nurse should:

Answer 5

ask questions about the client’s reason for seeking care.

Question 6

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. Which of the following is the nurse’s best response?

Answer 6

What exactly are these terrible voices saying to you?

Question 7

A graduate nurse is planning to perform a Romberg’s test on a client. The registered nurse would assess that the graduate nurse knows how to correctly perform this test when she sees the graduate nurse

Answer 7

Ask the client to try to balance himself with feet together and eyes open, and then eyes closed.

Question 8

A school-age child diagnosed with attention deficit hyperactivity disorder is prescribed methylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?

Answer 8

Loss of appetite.

Question 9

On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, “I look horrible! Will it ever look better?” Which of the following responses by the nurse would be most appropriate?

Answer 9

”You’re shocked by the sudden change in your appearance as a result of this surgery, aren’t you?”

Question 10

A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should:

Answer 10

Report the finding to the health care provider.

Question 11

Which situation violates the Health Insurance Portability and Accountability Act?

Answer 11

A nurse gives a client’s family members a report on his progress.

Question 12

When teaching a primigravid client at 24 weeks’ gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include?

Answer 12

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.

Question 13

While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother’s temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:

Answer 13

Continue to monitor the client’s vital signs.

Question 14

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Answer 14

Use a warm moist compress over the painful area.

Question 15

A nurse fails to give the evening dose of an I.V. antibiotic that is to be administered every 12 hours. The nurse should next:

Answer 15

Report the incident to the physician.

Question 16

The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child’s identity by checking the arm band and:

Answer 16

Asking the parent the child’s name.

Question 17

A physician orders gentamicin sulfate (Garamycin), 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least:

Answer 17

30 minutes.

Question 18

While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement?

Answer 18

I tell her she is wrong and then I tell her what’s right.

Question 19

A female client with gonorrhea informs the nurse that she has had sexual intercourse with her boyfriend and asks the nurse, “Would he have any symptoms?” The nurse responds that in men the symptoms of gonorrhea include:

Answer 19

Dysuria.

Question 20

Which nursing action would be most successful in gaining a preschooler’s cooperation in preparing for surgery?

Answer 20

Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.

Question 21

A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?

Answer 21

Sew thick padding into the elbows and knees of the child’s clothing.

Question 22

Which of the following statements indicates that the client understands the home care of a colostomy?

Answer 22

”I should be able to establish a regular pattern of elimination with my colostomy.”

Question 23

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby’s breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of which of the following?

Answer 23

A normal pattern in infants of this age.

Question 24

An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods and liquids through a syringe. The nurse determine’s his biggest nutritional risk factor is:

Answer 24

Impaired oral motor control.

Question 25

After the nurse counsels a primiparous client who is breastfeeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?

Answer 25

“I should drink at least five glasses of fluid daily.”

Question 26

A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client’s room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?

Answer 26

If you’re thinking about organ donation, my sister is waiting for a kidney transplant. She’d be an excellent recipient. I can give you her phone number.

Question 27

During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?

Answer 27

A sachet of lavender.

Question 28

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

Answer 28

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client’s weight.

Question 29

Which of the following indicates the client with ulcerative colitis has attained an expected outcome of nursing care?

Answer 29

The client maintains an ideal body weight.

Question 30

The nurse is assisting a client with a stroke who has homonymous hemianopia? The client will:

Answer 30

Eat food on only half of the plate.

Question 31

Initial client assessment information includes: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?

Answer 31

Headache, blurred vision, and facial and extremity swelling

Question 32

A client with stage 1 Alzheimer’s disease is diagnosed with terminal lung cancer. He asks the nurse what he should do when he “reaches the end.” How should the nurse respond?

Answer 32

An advance directive will help to make sure that your wishes are carried out.

Question 33

A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The child’s history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation?

Answer 33

Immediate isolation is required.

Question 34

The mother of a 14-year-old girl who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which of the following responses by the nurse is appropriate?

Answer 34

Tell me what you have found in your reading that is leading you to that conclusion.

Question 35

A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client has chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?

Answer 35

Call the rapid response team.

Question 36

A client has been prescribed digoxin (Lanoxin). Which of the following symptoms should the nurse tell the client to report as a potential indication of digoxin toxicity?

Answer 36

Visual disturbances.

Question 37

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

Answer 37

Making a copy of the incident report for the client

Question 38

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan? Check all that apply.

Answer 38

• Introducing foods on the unaffected side of the mouth.
• Maintaining an upright position while eating.
• Keeping distractions to a minimum.

Question 39

To prevent catheter-associated urinary tract infection, the nurse should do which of the following? Select all that apply.

Answer 39

• Assess the client for signs of infection.
• Provide perineal care several times a day.
• Encourage the client to drink 3,000 ml of fluids a day.

Question 40

During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks’ gestation and is now in her third trimester states, “I’ve been having strange dreams about the baby. Last week I dreamed he was covered with hair.” The nurse should tell the mother:

Answer 40

It’s not uncommon to have dreams about the baby, particularly in the third trimester.

Question 41

A client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions? Select all that apply.

Answer 41

• Take daily weight.
• Assess urine specific gravity.
• Monitor intake and output.

Question 42

While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which of the following PaCO2 values as indicating the need for immediate intervention?

Answer 42

80 mm Hg.

Question 43

A client has bursitis in the subacromial bursa. A nurse determines that the client understands teaching when the client says which of the following?

Answer 43

I will apply moist heat to my shoulder for 20 minutes three times each day.

Question 44

A nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should emphasize the fact that:

Answer 44

most toddler deaths are accidental.

Question 45

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?

Answer 45

No, it can initiate premature uterine contractions.

Question 46

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which of the following would be the most effective method of follow-up?

Answer 46

Weekly visits by a community health nurse.

Question 47

During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use?

Answer 47

1 mg I.V.

Question 48

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)?

Answer 48

Obtaining vital signs during blood administration

Question 49

A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?

Answer 49

• Stop the transfusion.
• Keep the I.V. open with normal saline infusion.
• Notify the attending physician and blood bank.
• Complete the appropriate Transfusion Reaction Form(s).

Question 50

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:

Answer 50

Moderate pain that worsens on inspiration.

Question 51

A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?

Answer 51

Anticipatory grieving

Question 52

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after complaining of feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. The nurse should do which of the following from first to last?

Answer 52

• Monitor for suicide and self-mutilation.
• Monitor sleeping and eating behaviors.
• Discuss the issues of loneliness and emptiness.
• Discuss her housing options for after discharge.

Question 53

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?

Answer 53

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

Question 54

A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?

Answer 54

Foul-smelling discharge from the penis

Question 55

A client receiving chemotherapy has pruritus. In order to develop a care plan, the nurse should ask if the client has been:

Answer 55

Taking daily baths with a deodorant soap.

Question 56

Which of the following client statements identifies a knowledge deficit about cast care?

Answer 56

I can pull out cast padding to scratch inside the cast.

Question 57

When a client cannot read or write but is of sound mind, the nurse should read the consent to the client in the presence of two witnesses and:

Answer 57

Have the client put an “X” on the signature line.

Question 58

A nurse is interviewing the mother of a 7-year-old child. Which symptom reported by the mother leads the nurse to suspect that the child has type 1 diabetes?

Answer 58

Recent bed-wetting

Question 59

A clinic client taking disulfiram (Antabuse) during alcohol rehabilitation therapy reports to the nurse that he has a mild cold and plans to use a cough medicine. What information about the use of cough medicine with disulfiram does the client need to know?

Answer 59

The client may experience violent vomiting if he takes cough medicine while taking disulfiram.

Question 60

Which of the following positions is appropriate for palpating tissues during breast self-examination?

Answer 60

Flat on the back with a pillow under the shoulder of the side being examined.

Question 61

The purpose of biofeedback is to enable a client to exert control over physiologic processes by:

Answer 61

Translating the signals of body processes into observable forms.

Question 62

A nurse is making assignments for the infant unit. The shift’s team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN?

Answer 62

An infant requiring abdominal dressing changes for a wound infection

Question 63

After receiving a change-of-shift report in the normal newborn nursery, which neonate should the nurse see first?

Answer 63

Neonate B: 4 hours old with a blood glucose level of 30.

Question 64

The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:

Answer 64

Hemorrhage.

Question 65

Which of the following questions or statements should the nurse use to encourage client evaluation of his or her own behavior?

Answer 65

What did you do differently with your coworker this time?

Question 66

When assessing a 34-year-old multigravid client at 34 weeks’ gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?

Answer 66

Painless vaginal bleeding.

Question 67

A client with gastric cancer is having a resection. What is the nursing management priority for this client?

Answer 67

Correcting nutritional deficits

Question 68

A nurse is administering indomethacin to a neonate. To ensure that the nurse has identified the neonate correctly, the nurse should do which of the following? Select all that apply.

Answer 68

• Check the neonate’s identification band against the medical record number.
• Verify the date of birth from the medical record with the date of birth on the client’s identification band.

Question 69

A client with bipolar disorder, manic phase, is scheduled for a chest radiograph. Before taking the client to the radiology department, the nurse should:

Answer 69

Explain the procedure in simple terms.

Question 70

The nurse is teaching the mother of a newborn to develop her baby’s sensory system. To further improve the infant’s most developed sense, the nurse should instruct the mother to:

Answer 70

Stroke the newborn’s cheek with her nipple to direct the baby’s mouth to nipple.

Question 71

What is the rationale that supports multidrug treatment for clients with tuberculosis?

Answer 71

Multiple drugs reduce development of resistant strains of the bacteria.

Question 72

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she’s admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress?

Answer 72

Blood pressure of 146/90 mm Hg

Question 73

A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?

Answer 73

I’ll call my neighbor who’s 2 months pregnant and tell her not to have contact with my son.

Question 74

A client at 28 weeks’ gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:

Answer 74

promote fetal lung maturity.

Question 75

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

Answer 75

at least three times per week.

Question 76

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:

Answer 76

Ineffective airway clearance.

Question 77

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The primary care provider is calling in a telephone order for ampicillin. The nurse should do which of the following? Select all that apply.

Answer 77

• Repeat the order to the primary health care provider.
• Ask the primary health care provider to confirm that the order is correct as understood by the nurse.

Question 78

A 5-month-old infant is brought to the clinic by his parents because he “cries too much” and “vomits a lot.” The infant’s birth weight was 6 lb, 10 oz, and his current weight is 7 lb, 4 oz, falling below the 5th percentile on a standard growth chart. Which of the following data should the nurse identify as the priority?

Answer 78

Feeding pattern.

Question 79

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

Answer 79

You must avoid coughing, sneezing, and blowing your nose.

Question 80

A client admitted to the psychiatric unit for treatment of a panic attack comes to the nurses’ station in obvious distress. After finding the client short of breath, dizzy, trembling, and nauseated, a nurse should first:

Answer 80

escort the client to a quiet area and suggest that he use a relaxation exercise he’s been taught.

Question 81

A 2-year-old child with a low blood level of the immunosuppressive drug cyclosporine comes to a liver transplant clinic for her appointment. The mother says the child hasn’t been vomiting and hasn’t had diarrhea, but she admits that her daughter doesn’t like taking the liquid medication. Which statement by the nurse is most appropriate?

Answer 81

Offer the medication diluted with chocolate milk or orange juice to make it more palatable.

Question 82

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client he’ll receive during this test?

Answer 82

Edrophonium (Tensilon)

Question 83

A client who is on nothing-by-mouth status is constantly asking for a drink. Which of the following is the most appropriate nursing intervention?

Answer 83

Offer the client frequent oral hygiene care.

Question 84

A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 ml. Urine output that’s less than 50 ml in 24 hours is known as:

Answer 84

anuria.

Question 85

A client is G2 P1, at term, completely effaced, and dilated to 2 cm. Her contractions are happening every 3 minutes and lasting 45 seconds each time. The client is asking for an epidural to make her more comfortable. Indicate the appropriate response by the nurse.

Answer 85

It is too early in labor for the epidural, but your obstetrician has ordered IV medication to keep you comfortable until you have dilated 1 to 2 cm more.

Question 86

The breast-feeding mother of a 1-month-old diagnosed with cow’s milk sensitivity asks the nurse what she should do about feeding her infant. Which of the following recommendations would be most appropriate?

Answer 86

Continue to breast-feed but eliminate all milk products from your own diet.

Question 87

A 21-year-old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of discharge teaching? Select all that apply.

Answer 87

• “I can apply an ice pack or a cold compress to the puncture site.”
• “I will take Tylenol for pain.”
• “I will not be able to play basketball for the next 2 days.”

Question 88

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Answer 88

Assessing the extremity for neurovascular integrity

Question 89

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:

Answer 89

Revascularize the blocked coronary artery.

Question 90

A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition?

Answer 90

Digoxin toxicity.

Question 91

The nurse should carefully observe a client with internal radium implants for typical adverse effects associated with radiation therapy to the cervix. These effects include:

Answer 91

Nausea and a foul vaginal discharge.

Question 92

A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching?

Answer 92

We’ll go to the physician if our child pulls on the ears or won’t lie down.

Question 93

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion?

Answer 93

Fetal heart rate variability within 5 to 10 beats/minute

Question 94

The client with diabetes mellitus says, “If I could just avoid what you call carbohydrates in my diet, I guess I would be okay.” The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following?

Answer 94

Proteins, fats, and carbohydrates.

Question 95

The nurse is caring for several neonates in the newborn nursery. Precautions that should be taken to prevent an infant abduction include which of the following?

Answer 95

Notifying the hospital’s security staff about anyone who appears unusual.

Question 96

The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?

Answer 96

Absence of drainage from the ileostomy for 6 or more hours.

Question 97

A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, “You look angry.” The nurse is using which technique?

Answer 97

Making observations

Question 98

A client changes topics quickly while relating past psychiatric history. This client’s pattern of thinking is called:

Answer 98

flight of ideas.

Question 99

A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks’ gestation. The assessments during this visit include BP 140/90, P 80, and + 2 edema of the ankles and feet. What further information should the nurse obtain to determine if this client is becoming preeclamptic?

Answer 99

Proteinuria.

Question 100

A client diagnosed with thyroid cancer signed a living will that states he doesn’t want ventilatory support if his condition deteriorates. As his condition worsens, the client states, “I changed my mind. I want everything done for me.” Which response by the nurse is best?

Answer 100

What exactly do you mean by wanting ‘everything’ done for you?

Question 101

A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer?

Answer 101

Pace yourself and rest frequently, especially after activities.

Question 102

When auscultating a client’s chest, a nurse assesses a second heart sound (S2). This sound results from:

Answer 102

closing of the aortic and pulmonic valves.

Question 103

The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique?

Answer 103

Nasogastric (NG) tube placement

Question 104

A nurse has just removed an I.V. catheter from a client’s arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should:

Answer 104

remove the warm compress for at least 15 minutes after each 20-minute application.

Question 105

A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

Answer 105

To prevent evaporation of water from the hydrated epidermis.

Question 106

Which of the following indicate that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?

Answer 106

Maintenance of joint mobility.

Question 107

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which of the following comments by the client supports the fact that the client may not need counseling?

Answer 107

Since I’ve gotten over the death of my husband, I’ve had more energy and been more active than before he died.

Question 108

A nurse is reviewing her shift assignment. Which child should she assess first?

Answer 108

An 11-month-old infant receiving chemotherapy through a central venous catheter

Question 109

The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply.

Answer 109

• Monitor temperature and report elevation.
• Maintain integrity of skin and mucous membranes.
• Recognize signs and symptoms of infection.
• Avoid crowds.

Question 110

During an emergency, a physician has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should:

Answer 110

Check with the physician for his complete order.

Question 111

A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?

Answer 111

Initiating caloric and nutritional therapy as ordered

Question 112

Which client is at highest risk for developing a hospital-acquired infection?

Answer 112

A client with an indwelling urinary catheter

Question 113

A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the primary health care provider with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply.

Answer 113

• Maintain a sterile field.
• Ensure a patent airway.
• Hold the neonate steady in the correct position.

Question 114

A client has progressed through the first stage of labor. Which assessment finding suggests she’s in the transition to the second stage?

Answer 114

Bulging of the vaginal introitus

Question 115

An elderly man experiences a thrombotic cerebrovascular accident and subsequent flaccid hemiplegia of the right side. When planning care for this client, rehabilitation begins:

Answer 115

When the client is admitted to the hospital.

Question 116

What is the primary goal of nursing care during the emergent phase after a burn injury?

Answer 116

Replace lost fluids.

Question 117

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3–), 15 mEq/L. These ABG values suggest which disorder?

Answer 117

Metabolic acidosis

Question 118

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

Answer 118

Before you do the exercise, I’ll give you pain medication if you need it.

Question 119

A nurse is reviewing a report of a client’s routine urinalysis. Which value requires further investigation?

Answer 119

Urine pH of 3.0

Question 120

A physician orders an I.V. bolus injection of diltiazem hydrochloride (Cardizem) for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Answer 120

Gently aspirate the I.V. catheter to check for a blood return.

Question 121

A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?

Answer 121

The physician will document the emergency nature of the client’s condition and that an ICP catheter for monitoring was placed without a consent.

Question 122

Two parents who are arguing in their infant’s room, with voices raised and getting louder, start to hit each other. The infant is crying. Which of the following actions should the staff nurse take next?

Answer 122

Remove the infant from the room.

Question 123

Six hours after undergoing an abdominal hysterectomy, a client has a strong urge to void and voids 25 ml into the bedpan. Based on these data, the nurse determines that the client:

Answer 123

Is experiencing urine retention and needs to be catheterized.

Question 124

A client has a C7 spinal cord injury. Which of the following would be the most important nursing intervention during the acute stage of the injury?

Answer 124

Maintaining a patent airway.

Question 125

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes and her cervix is 3/100/-1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. The priority action by the nurse is to:

Answer 125

Notify the provider of the pain and request an assessment for potential abruption.

Question 126

A client who gave birth to her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, “I can’t keep up with my housework any more because I spend so much time caring for the baby.” The nurse should:

Answer 126

help the client break down large tasks into smaller ones.

Question 127

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Answer 127

Impaired gas exchange

Question 128

The daughter of a client with Alzheimer’s disease tells the nurse that her mother thinks someone is stealing her things. Which of the following responses by the nurse would be most helpful?

Answer 128

I’ll check, but your mother may be having paranoid delusions, which are common in people with Alzheimer’s disease.

Question 129

A nurse prepares to measure a client’s blood pressure. What is the correct procedure for measuring blood pressure?

Answer 129

Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference

Question 130

A client arrives in the emergency department following a bicycle accident in which the client’s forehead hit the pavement. The client is diagnosed with a hyphema. The nurse should place the client in which position?

Answer 130

Semi-Folwer’s

Question 131

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?

Answer 131

Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided.

Question 132

After the nurse teaches a client about wearing a back brace after a spinal fusion, which of the following client statements indicates effective teaching?

Answer 132

I should wear a thin cotton undershirt under the brace.

Question 133

A potential concern when caring for an older adult who has diminished hearing and vision is the client’s:

Answer 133

Social isolation.

Question 134

On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, the nurse should consider which of the following?

Answer 134

The boys probably fear punishment.

Question 135

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation?

Answer 135

Tachycardia

Question 136

A nurse must administer an enema to an adult client. The appropriate depth for inserting an enema into an average-sized adult is:

Answer 136

3″ to 4″.

Question 137

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?

Answer 137

Change the tube feeding administration set at least every 24 hours.

Question 138

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

Answer 138

Tachycardia, weight loss, and mood swings

Question 139

A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action?

Answer 139

Prepare for cesarean birth.

Question 140

The nurse is developing a primary disease prevention program for older adults. Which of the following is the most appropriate topic?

Answer 140

Immunizations for influenza.

Question 141

The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant’s diet at age:

Answer 141

5 to 6 months.

Question 142

A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

Answer 142

Tremors, shuffling gait, and masklike face

Question 143

The nurse is observing a nursing assistant give care to a client after gynecologic surgery. The nurse should intervene if the nursing assistant does which of the following?

Answer 143

Massages the client’s legs.

Question 144

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:

Answer 144

Dependent edema.

Question 145

The nurse is teaching the client who is receiving chemotherapy and the family how to manage possible nausea and vomiting at home. The nurse should include information about:

Answer 145

Eating frequent, small meals throughout the day.

Question 146

A physician orders lithium carbonate (Eskalith) for a client who has just been diagnosed with bipolar disorder. The nurse is teaching the client about signs and symptoms of lithium toxicity, which include:

Answer 146

lethargy, vomiting, and diarrhea.

Question 147

Which of the following findings in a client’s history would most likely increase the client’s risk for renal calculi?

Answer 147

The client drinks one to two glasses of fluid daily.

Question 148

The husband of a client who is experiencing acute mania and is swearing and using profanity apologizes to the nurse for his wife’s behavior. Which of the following replies by the nurse is most therapeutic?

Answer 148

This must be difficult for you.

Question 149

The client has sore nares while a nasogastric (NG) tube is in place. Which of the following nursing measures would be most appropriate to help alleviate the client’s discomfort?

Answer 149

Apply a water-soluble lubricant to the nares.

Question 150

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

Answer 150

skin test doesn’t differentiate between active and dormant tuberculosis infection.

Question 151

A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client’s nursing care with the understanding that acute angle-closure glaucoma:

Answer 151

Is a medical emergency that can rapidly lead to blindness.

Question 152

Which of the following indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client:

Answer 152

Takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

Question 153

A physician placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?

Answer 153

Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR)

Question 154

When preparing a teaching plan for an adult client about general anesthesia induction, which explanation would be most appropriate?

Answer 154

You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy.

Question 155

During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks’ gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following?

Answer 155

Respiratory distress syndrome.

Question 156

A 30-year-old client, hospitalized with a fractured femur being treated with skeletal traction, has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?

Answer 156

Increase the client’s fluid intake to 3,000 ml/day.

Question 157

A mother reports that her school-age child is having some problems in school. Which action would be the priority?

Answer 157

Obtain more information from the mother and the child.

Question 158

The nurse is ready to administer a partial fill of imipenem-cilastatin (Primaxin) in the I.V. pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client’s bedside. The nurse should do which of the following first?

Answer 158

Determine when the client received the last dose of the imipenem-cilastatin.

Question 159

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Answer 159

Shock

Question 160

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

Answer 160

Aorta

Question 161

A 10 year old with a severe head injury is unconscious and has coarse breath sounds, a temperature of 39 degrees C (102.2 degrees F), a heart rate of 70, a blood pressure of 130/90, and an intracranial pressure of 36 mm Hg. Which of the following actions should the nurse perform first?

Answer 161

Administer IV mannitol (Osmitrol).

Question 162

The nurse planning care for a group of clients who are chronically mentally ill. Which of the following strategies is likely to be the least beneficial for the client population?

Answer 162

Helping clients in insight-oriented therapy.

Question 163

The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?

Answer 163

Noisy respirations.

Question 164

The State Health Department notifies a nursery staff nurse of a phenylketonuria (PKU) metabolic screening test result of 7 mg/dl for a neonate discharged several days ago. What should the nursery nurse do?

Answer 164

Immediately notify the physician because the test result is critically elevated.

Question 165

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which of the following as characteristic of abusive families?

Answer 165

Role stereotyping.

Question 166

A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether to file a report, the nurse’s next priority is to offer which of the following to the client?

Answer 166

Crisis intervention.

Question 167

In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a desired outcome for the client? The client will:

Answer 167

Maintain current weight.

Question 168

Which of the following groups has experienced the greatest rise in the incidence of sexually transmitted diseases (STDs) over the past two decades?

Answer 168

Teenagers.

Question 169

A nurse is caring for a client who had an ileal conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation?

Answer 169

Red, sensitive skin around the stoma site

Question 170

A client has been admitted to the emergency department with alcohol withdrawal delirium. The nurse is assessing the client for signs of withdrawal. At 9 a.m. on 10/25, the nurse notes that the client is confused. His vital signs are T = 99° F, P = 50, R = 10, and BP = 100/60. The nurse compares these findings to the nurses’ progress notes from admission 24 hours ago (see below). What should the nurse do ?

Answer 170

Contact the primary health care provider.

Question 171

A nurse must apply an elastic bandage to a client’s ankle and calf. She should apply the bandage beginning at the client’s:

Answer 171

foot.

Question 172

When palpating the bladder of an adult client, a nurse should identify which finding as normal?

Answer 172

A nonpalpable bladder

Question 173

A child’s parents state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the parents don’t fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the parents?

Answer 173

Toy chest in front of a second-story, locked window

Question 174

The nurse notices that a client with Parkinson’s disease is coughing frequently when eating. Which one of the following interventions should the nurse consider?

Answer 174

Thicken all liquids before offering to the client.

Question 175

What is a generally accepted criterion of mental health?

Answer 175

Self-acceptance

Question 176

Which statement indicates that a client with diabetes mellitus understands proper foot care?

Answer 176

I’ll wear cotton socks with well-fitting shoes.

Question 177

A nurse is teaching an adolescent with inflammatory bowel disease about treatment with corticosteroids. Which adverse effects are concerns for this client? Select all that apply.

Answer 177

• Acne
• Hirsutism
• Mood swings
• Osteoporosis
• Adrenal suppression

Question 178

Which of the following is an environmental factor that increases the risk of cancer?

Answer 178

Nutrition.

Question 179

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed his wish to not be intubated with his girlfriend of 5 years, whom he’s designated as his health care power of attorney. The client’s children want their father to be intubated. A nurse caring for this client knows that:

Answer 179

clients commonly confer health care power of attorney on someone who shares their personal values and beliefs.

Question 180

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

Answer 180

Ketones will tell us if your body is using other tissues for energy.

Question 181

A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride (Xylocaine), an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within:

Answer 181

1 to 2 minutes after I.V. bolus administration.

Question 182

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

Answer 182

Hypertonic

Question 183

Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?

Answer 183

Auscultation of bowel sounds.

Question 184

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child’s temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3. Which of the following is priority for nursing intervention?

Answer 184

Airway obstruction.

Question 185

A client is color blind. The nurse understands that this client has a problem with:

Answer 185

cones.

Question 186

A client with pneumonia has a temperature of 102.6 ° F (39.2 ° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?

Answer 186

Frequent linen changes.

Question 187

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following?

Answer 187

History of cerebral hemorrhage.

Question 188

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should:

Answer 188

ask the client to void.

Question 189

When a nurse tries to administer medication, the client refuses it, saying, “I don’t have to take those pills if I don’t want to. What good will they do?” Which action by the nurse would be most appropriate?

Answer 189

Exploring how the client’s feelings affect his decision to refuse medication

Question 190

Which nursing diagnosis takes highest priority for a client with a compound fracture?

Answer 190

Risk for infection related to effects of trauma

Question 191

Which of the following has the highest priority in the care of a client with chronic renal failure?

Answer 191

Maintain a low-sodium diet.

Question 192

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:

Answer 192

Stay with the client during the first 15 minutes of infusion.

Question 193

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned?

Answer 193

36

Question 194

The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the nursing assistant?

Answer 194

• Obtaining vital signs.
• Applying antiembolic stockings.
• Keeping the client oriented.

Question 195

A fourth heart sound (S4) indicates a:

Answer 195

failure of the ventricle to eject all blood during systole.

Question 196

Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he needs to follow at home?

Answer 196

I should avoid alcohol and caffeine.

Question 197

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the primary care provider to further assess the baby and request a prescription for:

Answer 197

An x-ray with orogastric catheter placement.

Question 198

Lower back pain is a common complaint among pregnant clients. Which comfort measure should a nurse include in her teaching plan for a pregnant client?

Answer 198

Use an ergonomically correct desk chair.

Question 199

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?

Answer 199

Left lateral

Question 200

A woman is taking oral contraceptives. The nurse teaches the client that medications that may interfere with oral contraceptive efficacy include:

Answer 200

Antibiotics.