All Clients Need (0401-0600)

Question 1

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches him about dietary sources of minerals. Which foods are good sources of zinc?

Answer 1

Whole grains and meats

Question 2

A nurse is caring for a client who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply.

Answer 2

• Changes in sleeping and eating patterns may be signs of stress in a family.
• A family member may have more than one role at a time in the family.
• The effects of an illness on a family depend on the stage of the family’s life cycle.
• Illness in one family member can affect all family members.

Question 3

A nurse is caring for a client she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:

Answer 3

euphoria and constricted pupils.

Question 4

A nurse is assessing a client with possible osteoarthritis. The most significant risk factor for primary osteoarthritis is:

Answer 4

age.

Question 5

The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which of the following explanations should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision?

Answer 5

The foreskin is used to repair the deformity surgically.

Question 6

In a client with enteritis and frequent diarrhea, the nurse should anticipate:

Answer 6

metabolic acidosis.

Question 7

A client who has had the jaws wired begins to vomit. What should be the nurse’s first action?

Answer 7

Suction the client’s airway as needed.

Question 8

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Answer 8

Placing the client in respiratory isolation

Question 9

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

Answer 9

My finger joints are oddly shaped.

Question 10

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

Answer 10

All weight should be on the hands.

Question 11

A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:

Answer 11

Obtain the child’s blood pressure.

Question 12

An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be closely monitored for which of the following complications?

Answer 12

Hypoventilation.

Question 13

A nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

Answer 13

fine crackles.

Question 14

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

Answer 14

15-mm induration

Question 15

A diabetic postpartum client plans to breastfeed. The nurse determines that the client’s understanding of breastfeeding instructions is sufficient when she states:

Answer 15

“Breastfeeding will assist in lowering maternal blood glucose.”

Question 16

For healing by secondary intention, a client’s wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?

Answer 16

The granulation tissue is at the wound edges.

Question 17

A client is scheduled for a colonoscopy in 2 days. The nurse is instructing the client on actions to take the day before the procedure. Place the instructions in the order the client should perform the tasks, from first to last.

Answer 17

• Follow a clear liquid diet.
• Drink one bottle of citrate of magnesia.
• Drink 1 gallon of bowel preparation.
• Remain NPO.

Question 18

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?

Answer 18

Droplet precautions.

Question 19

When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the neonate must have received which of the following to ensure reliable results?

Answer 19

Initial formula or breast milk at least 24 hours before the test.

Question 20

The parent of an 18-year-old with chronic renal disease states, “My son has so many problems. I’m really worried that he will not get the right care if he gets sick at college.” The nurse should tell the parent:

Answer 20

Your son can make an e-health history to facilitate his care if he gets sick away from home.

Question 21

In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which of the following statements by the mother indicates successful teaching?

Answer 21

I need to wash my hands more often.

Question 22

Which of the following nursing interventions will promote successful achievement of Erikson’s stage of development for the 3–year-old toddler?

Answer 22

Encouraging the toddler to assist in removing a dressing on the leg.

Question 23

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn’t want to be placed on a ventilator. What action should the nurse take?

Answer 23

Notify the physician immediately so he can determine client competency.

Question 24

A client with Raynaud’s phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:

Answer 24

Reduced episodes of finger numbness.

Question 25

A 14-year-old adolescent on her third admission for panic attacks tells the nurse that her uncle has been making sexual advances toward her. She begs the nurse to not say anything because she’s afraid of what her uncle will do. What should be the nurse’s initial response?

Answer 25

The law requires me to make a report so you can be protected.

Question 26

Because a client’s renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?

Answer 26

Milk, apples, tomatoes, and corn.

Question 27

A nurse is teaching a client with osteomalacia how to take ordered vitamin D supplements. Which adverse effects should the nurse instruct the client to report?

Answer 27

GI upset and metallic taste

Question 28

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a:

Answer 28

Micron mesh filter.

Question 29

A school-age child is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child’s risk of infection?

Answer 29

Practicing thorough hand washing

Question 30

Which plane divides the body longitudinally into anterior and posterior regions?

Answer 30

Frontal plane

Question 31

Which step must be done first when administering a blood transfusion?

Answer 31

Verify the physician’s order.

Question 32

The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first:

Answer 32

Administer oxygen.

Question 33

On admission to the inpatient psychiatric unit, a client’s facial expression indicates severe panic. He repeatedly states, “I know the police are going to shoot me. They found out that I’m the child of the devil.” What should the nurse say to initiate a therapeutic relationship with this client?

Answer 33

Hello, my name is ___. I’m a nurse, and I’ll care for you when I’m on duty. Should I call you ___, or do you prefer something else?

Question 34

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:

Answer 34

I’ll stop being contagious when I have a negative acid-fast bacilli test.

Question 35

An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client’s self-efficacy to manage their disease, the nurse should:

Answer 35

Utilize a peer with type 2 diabetes to role model lifestyle changes.

Question 36

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:

Answer 36

Place the client on nothing-by-mouth (NPO) status.

Question 37

Which nursing action is required before a client in labor receives epidural anesthesia?

Answer 37

Give a fluid bolus of 500 ml.

Question 38

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:

Answer 38

enteric precautions must be continued.

Question 39

Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct?

Answer 39

An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.

Question 40

A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which of the following would the nurse include in the teaching plan?

Answer 40

Cervical mucus is carefully monitored for changes.

Question 41

A client with depression and suicidal ideation voices feelings of self-doubt and powerlessness and is very dependent on the nurse for most aspects of her care. According to Erikson’s stages of growth and development, the nurse determines the client to be manifesting problems in which of the following stages?

Answer 41

Autonomy versus shame/doubt.

Question 42

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, she realizes the client doesn’t fully understand the surgery. She approaches the physician, who curtly says, “I’ve told him all about it. Just get the consent.” The nurse should:

Answer 42

tell the physician the client isn’t comfortable consenting to surgery at this point.

Question 43

A child, age 9, is admitted to the emergency department with abdominal pain. The child’s mother states the pain began about 12 hours ago. The nurse notes the child has a temperature of 100.8° F (38.2° C) and nausea. The child vomited once. Which abdominal area would be most appropriate for the nurse to assess?

Answer 43

Lower right abdominal quadrant

Question 44

Twenty-four hours after an appendectomy, a 16-year-old adolescent of Asian ethnicity has no pain but is frowning and has the legs drawn to the fetal position. The nurse should:

Answer 44

Administer pain medication.

Question 45

A client with a history of osteoarthritis is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes?

Answer 45

Including the client in developing a care plan that works toward meeting discharge goals

Question 46

A nurse is caring for a client who has been diagnosed with hypochondriasis. The client attributes his cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially?

Answer 46

Report the client’s complaint of chest pain to a physician.

Question 47

Twenty-four hours after birth, a neonate hasn’t passed meconium. The nurse suspects which condition?

Answer 47

Hirschsprung’s disease

Question 48

A nurse is caring for a client with bipolar disorder. The care plan for a client in a manic state would include:

Answer 48

listening attentively to the client’s requests with a neutral attitude, and avoiding power struggles.

Question 49

The nurse is conducting a community health education program about cervical cancer. The nurse should include which as a priority when teaching about cervical cancer?

Answer 49

The peak incidence is 20 to 30 years of age in both African-American and Caucasian women.

Question 50

The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply.

Answer 50

• Clients must eat within view of a staff member.
• Clients are not told their weight and cannot see their weight while being weighed.
• Clients must rest within view of a staff member and not go o the bathroom for one half hour to an hour after eating.

Question 51

When formulating outcomes for the post-term neonate at discharge, which of the following would be most appropriate?

Answer 51

Maintenance of normal body temperature.

Question 52

A client is induced with oxytocin (Pitocin). The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?

Answer 52

Document fetal well-being.

Question 53

The nurse manager is developing a “read-back” procedure to reduce medication administration errors. Which of the following are purposes of the “read-back” requirement? Select all that apply.

Answer 53

• To make sure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
• To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.

Question 54

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

Answer 54

Encouraging increased fluid intake

Question 55

Which of the following should be the nurse’s priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor?

Answer 55

Blood pressure.

Question 56

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply.

Answer 56

• Ask the client if he has a headache.
• Determine if the client’s pupils are equal and react to light

Question 57

A 20-year-old man is seriously ill with cystic fibrosis (CF), which he has had since infancy. The client is frequently hospitalized for lung infections and needs a lung transplant. His rare blood type complicates the process of obtaining a donor organ. He also has bipolar disorder that has been treated successfully with medication and therapy since mid-adolescence. The client is currently hospitalized with pneumonia. How should the unit nurse interpret the client’s request for a chaplain to help him plan a funeral and donation of his body to science after death?

Answer 57

It is a signal of the client’s growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff.

Question 58

When administering an I.M. injection to a neonate, which of the following muscles should the nurse consider as the best injection site?

Answer 58

Vastus lateralis.

Question 59

An adolescent primigravid client at 26 weeks’ gestation has gained 25 lb since becoming pregnant. Which of the following is the recommended amount of weight gain during the third trimester?

Answer 59

1 lb per week.

Question 60

A client admitted to the hospital for chemotherapy states that he’s been using a peppermint-scented candle at home to help control nausea. Which interventions would the nurse plan to promote comfort for this client?

Answer 60

Asking the client to try using peppermint oil in place of scented candles

Question 61

Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:

Answer 61

Assess the client’s cervical dilation and station.

Question 62

Which of the following statements by the mother of a toddler diagnosed with nephrotic syndrome indicates that the mother has understood the nurse’s teaching about this disease?

Answer 62

My child really likes chips and bologna. I guess we’ll have to find something else.

Question 63

A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain, nausea, and has vomited several times. Based on these data, which nursing action would have the highest priority for intervention at this time?

Answer 63

Manage the pain.

Question 64

A client on the behavioral health unit tells a nurse that she was raped 5 months earlier. During the nurse’s assessment of this client’s sleep patterns, the client complains of having difficulty falling asleep and staying asleep. She attributes her irritability to sleep deprivation. Further questioning reveals that the client can’t recall details of the rape, and feels detached when she has sex with her husband. The nurse recognizes that this client is experiencing symptoms of what disorder?

Answer 64

Posttraumatic stress disorder (PTSD)

Question 65

When teaching an adolescent with a seizure disorder who is receiving valproic acid (Depakene), which sign or symptom should the nurse instruct the client to report to the health care provider?

Answer 65

Jaundice.

Question 66

Puerperium is defined as:

Answer 66

the 6 weeks following birth.

Question 67

A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

Answer 67

7 to 14 days

Question 68

A nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is appropriate?

Answer 68

The special medicine will feel warm when it’s put in the tubing.

Question 69

The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?

Answer 69

Decreased healing.

Question 70

A nurse is administering dexamethasone (Decadron) 4 mg I.V. to a client diagnosed with a brain tumor. The nursing assistant informs the nurse that the client’s fingerstick glucose level is 240 mg/dl. A sliding insulin scale hasn’t been ordered. How should the nurse intervene?

Answer 70

Notify the physician of the fingerstick glucose level, inquire about insulin therapy, and ask whether the dexamethasone should be administered.

Question 71

After teaching the mother of a young child with a peritoneal catheter about the signs and symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she identifies which of the following as an important sign?

Answer 71

Cloudy dialysate drainage return.

Question 72

The client who does not respond adequately to fluid replacement has an order for an I.V. infusion of dopamine hydrochloride at 5 µg/kg/minute. To determine that the drug is having the desired effect, the nurse should assess the client for:

Answer 72

Increased cardiac output.

Question 73

Which assessment is most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?

Answer 73

Oral temperature of 101° F (38.3° C)

Question 74

The nurse is a member of a team that is planning a client-centered approach to care of clients with chronic obstructive pulmonary disease (COPD) using the Chronic Care Model (CCM). The team should focus on improving quality of care and delivery in which of the following areas? Select all that apply.

Answer 74

• The community.
• Clinical information systems.
• Delivery system design.

Question 75

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

Answer 75

The system has an air leak.

Question 76

A child has viral pharyngitis. The nurse should advise the parents to do which of the following? Select all that apply.

Answer 76

• Use a cool mist vaporizer.
• Offer a soft-to-liquid diet.
• Administer acetaminophen

Question 77

A child, age 5, is brought to the pediatrician’s office for a routine visit. When inspecting the child’s mouth, the nurse expects to find how many teeth?

Answer 77

Up to 20

Question 78

A school nurse is examining a student at an elementary school. Which findings would lead the nurse to suspect impetigo?

Answer 78

Vesicular lesions that ooze, forming crusts on the face and extremities

Question 79

A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity?

Answer 79

Confusion and restlessness

Question 80

When a client has a tearing of tissue with irregular wound edges, the nurse should document this as:

Answer 80

Laceration.

Question 81

A nurse is reviewing a client’s prenatal history. Which finding indicates a genetic risk factor?

Answer 81

The client has a child with cystic fibrosis.

Question 82

A primigravid client at 10 weeks’ gestation tells the nurse that she eats fruits and vegetables but doesn’t like them. After teaching the client about accurate serving sizes, the nurse determines that the teaching has been successful when the client states that one serving of fruit is equivalent to which of the following?

Answer 82

One-fourth of a cantaloupe.

Question 83

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse’s best response?

Answer 83

Call the surgery unit to explain the client’s concern and ask if she can wear her hearing aid to surgery.

Question 84

For the client with catatonic behaviors, which of the following should the nurse use to determine that the medication administered as needed. has been most effective in the long term?

Answer 84

The client initiates simple activities without directions.

Question 85

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client:

Answer 85

Verbalizes safety precautions needed to prevent pacemaker malfunction.

Question 86

Which child most needs a developmental referral for a language delay?

Answer 86

The 4-year-old who is difficult to understand.

Question 87

A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the receipt of a divorce notice. Which of the following, if verbalized by the client, indicates to the nurse that the client is ready for discharge?

Answer 87

A list of support persons and community resources.

Question 88

The most appropriate suggestion for the hospice nurse to give a woman whose husband died 3 months ago and her three young children would be to:

Answer 88

Continue her bereavement support through hospice.

Question 89

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter’s care. She states, “The doctor said I can be in the room for up to 2 hours each day, but the nurses say they’re restricted to 30 minutes.” The nurse explains that this variation is based on the fact that nurses:

Answer 89

Work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.

Question 90

The nurse in the postanesthesia care unit notes that one of the client’s pupils is larger than the other. The nurse should:

Answer 90

Check the client’s baseline data.

Question 91

A 6 year old will have a cardiac catheterization. The child asks if the procedure will hurt. Which of the following statements provides the nurse with the best guide for responding to the child’s question?

Answer 91

The medication used to numb the insertion site will sting.

Question 92

In the immediate period following application of a plaster cast to correct a child’s congenital clubfoot, the nurse should:

Answer 92

Change the child’s position at least every 2 hours.

Question 93

A nurse is assessing a child who has a mild intellectual disability. The best indication of how this child is progressing can be obtained by observing him:

Answer 93

At school with his teacher.

Question 94

A 62-year-old female client with severe depression and psychotic symptoms is scheduled for electroconvulsive therapy (ECT) tomorrow morning. The client’s daughter asks the nurse, “How painful will the treatment be for Mom?” The nurse should respond by saying which of the following?

Answer 94

Your mother will be asleep during the treatment and will not be in pain.

Question 95

When should a nurse introduce information about the end of the nurse-client relationship?

Answer 95

During the orientation phase

Question 96

On the first day after surgery, a client has been breathing room air. Vital signs are normal and O2 saturation is 89%. The nurse should first:

Answer 96

Assist the client to take several deep breaths and cough.

Question 97

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client’s condition?

Answer 97

Decrease in level of consciousness (LOC).

Question 98

During the fourth stage of labor, the client should be assessed carefully for:

Answer 98

uterine atony.

Question 99

A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client’s teaching plan?

Answer 99

As ovulation approaches, cervical mucus is abundant and clear.

Question 100

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F. The client also has a headache and appears flushed. Place the following nursing actions in the order in which the nurse should perform them to properly respond to this client’s situation:

Answer 100

• Stop the blood infusion
• Infuse normal saline to keep the vein open
• Obtain a blood culture from the client.
• Send the blood bag and administration set to the blood bank.

Question 101

The primary care provider prescribes risperidone (Risperdal) 1 mg orally, two times a day for a client from a group home admitted to the hospital with severe anti-social behavior.The nurse determines that this dose is:

Answer 101

Typical when initiating therapy.

Question 102

After 2 months taking antidepressants, an elderly client reports no mood improvements. The client’s daughter tells the nurse she believes her father is drinking more alcohol because of the number of alcohol bottles in his apartment. The client denies any problem with drinking but states, “I am just so depressed.” In which order of priority from first to last should the nurse take the following actions?

Answer 102

• Express concern to the client about how hard it is for him to deal with his depression.
• Remind the client that the alcohol is probably making his depression worse.
• Ask the client’s primary care provider to assess the client’s depression and alcohol consumption.
• Refer the client for substance treatment.

Question 103

A multipara at 16 weeks’ gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should:

Answer 103

Explore nurse’s own feelings about the issues of anencephaly and organ donation.

Question 104

Which of the responsibilities related to the care of a client with a Foley catheter is appropriate for the nurse to delegate to the nursing assistant? Select all that apply.

Answer 104

• Apply catheter-securing device to the client’s leg.
• Ensure the urine drainage bag is below the level of the bladder at all times.
• Provide Foley catheter and perineal care each shift.
• Empty drainage bag and record output at specified times.

Question 105

The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which of the following?

Answer 105

Synthesis of proteins, nucleic acids, and fats.

Question 106

A depressed client remains alone in his room most of the time. Which of the following statements by the nurse would most likely help the client become involved with a unit activity?

Answer 106

I’ll be back at 4 o’clock to take you to the movie.

Question 107

A client attempting to get out of bed stops midway because of low back pain radiating down to the right heel and lateral foot. What should the nurse do in order of priority from first to last?

Answer 107

• Assist the client to lie down.
• Administer the prescribed celecoxib (Celebrex).
• Apply a warm compress to the client’s back.
• Notify the physician.

Question 108

A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says he’s concerned about the effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:

Answer 108

suggest referral to a sex counselor or other appropriate professional.

Question 109

A nurse can auscultate for heart sounds more easily if the client is:

Answer 109

leaning forward.

Question 110

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take?

Answer 110

Notify the nursing supervisor that she feels unqualified and untrained for the assignment.

Question 111

A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse should interpret which finding as a positive response to this drug?

Answer 111

Decreased urine output

Question 112

A 9-year-old boy with diabetes mellitus tests his glucose level in the nurse’s office before lunch. According to this sliding scale of insulin, he’s due for 1 unit of regular insulin. What steps should a nurse follow after confirming the medication order, washing her hands, drawing up the appropriate dose, verifying the boy’s identity, and putting on gloves? Put the following steps in chronological order. Use all options.

Answer 112

• Select appropriate injection site with the child.
• Clean site with an alcohol pad; loosen needle cover.
• Pinch the skin around the injection site.
• Uncover needle; insert at a 45- to 90-degree angle.
• Release the skin and give the injection.
• Cover the site with an alcohol pad.

Question 113

A client with benign prostatic hypertrophy (BPH) has an elevated prostate-specific antigen (PSA) level. The nurse should?

Answer 113

Determine if the prostatic palpation was done before or after the blood sample was drawn.

Question 114

A 15-year-old girl with anorexia nervosa has been admitted to a mental health unit. She refuses to eat. Which statement is appropriate for the nurse to make?

Answer 114

If you don’t eat, it may be necessary to feed you by tube or I.V.

Question 115

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client’s 6 a.m. glucose level is 300 mg/dl. The nurse should:

Answer 115

Call the physician for specific orders based on the glucose level.

Question 116

When caring for a child who has been receiving long-term steroid therapy, the nurse should assess the child for:

Answer 116

Development of truncal obesity.

Question 117

When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)?

Answer 117

External genitalia.

Question 118

The client has been taking magnesium hydroxide (milk of magnesia) to control hiatal hernia symptoms. The nurse should assess the client for which of the following conditions most commonly associated with the ongoing use of magnesium-based antacids?

Answer 118

Diarrhea.

Question 119

A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. The nurse should do which of the following first?

Answer 119

Place the toddler in a quiet environment.

Question 120

A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal delivery. The client is complaining of a warm, red, painful breast; a temperature of 100° F; and flulike symptoms. What should the nurse do?

Answer 120

Refer the woman to her primary health care provider.

Question 121

What information about vision would be most important for the nurse to include in the discharge plan of a client who had cataract removal?

Answer 121

”You will need to relearn to judge distances accurately.”

Question 122

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?

Answer 122

Observe individuals in the area for large bags or oversized coats.

Question 123

The nurse notices that a nurse colleague is wearing a lower lip ring. The nurse should do which of the following?

Answer 123

Request the nurse remove the ring.

Question 124

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103° F (39.4° C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order should the nurse perform the following actions?

Answer 124

• Open the airway.
• Start an I.V. access site.
• Call the physician.
• Explain the situation to the family

Question 125

A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of:

Answer 125

hallucination.

Question 126

The nurse should instruct the nursing assistant to obtain the body temperature at what site for the client with a productive cough and difficulty breathing?

Answer 126

Ear.

Question 127

To examine an infant’s thyroid gland, the nurse should place the infant in which position?

Answer 127

Supine

Question 128

Several day-shift nurses complain that the night-shift nurses aren’t performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to:

Answer 128

review the capillary glucose monitoring calibration log book.

Question 129

A client with Hodgkin’s disease explains the monitoring that needs to be done at home between radiation treatments. Which of the following statements would indicate that the client knows how to detect a major complication?

Answer 129

”I’ll take my temperature every day.”

Question 130

A physician has ordered a new antipsychotic medication for a client with schizophrenia whose previous medication no longer provides the expected symptom relief. When the client tells the nurse that his insurance company won’t reimburse him for the cost of this new medication, what is the first action the nurse should take to help the client advocate for his needs?

Answer 130

Help the client explore other financial options for obtaining medication reimbursement.

Question 131

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client’s leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive?

Answer 131

Kernig’s sign

Question 132

Which of the following nursing actions would be most appropriate immediately after nasogastric (NG) tube removal?

Answer 132

Provide the client with mouth care.

Question 133

To help control pain during coughing for a client who has had a pulmonary lobectomy, the nurse should:

Answer 133

Raise the bed to semi-Fowler’s position and position the client’s hands so that the incision is supported anteriorly and posteriorly.

Question 134

A 15-month-old child with an I.V. line in place is ordered to receive a total of 200 ml over the next 3 hours. The infusion set delivers 1 ml per 60 drops. At what rate should the nurse run the infusion?

Answer 134

67

Question 135

A client is being given naltrexone (ReVia) as part of an alcohol treatment program. When the client asks the nurse to explain the intended effects of the drug, the nurse should state that the drug:

Answer 135

reduces compulsions to drink.

Question 136

In developing a plan of care for a client with rheumatoid arthritis, the nurse should position the client to:

Answer 136

Prevent flexion deformities of the joints.

Question 137

Which of the following nursing interventions would be most helpful in improving the respiratory effort of a client with metastatic lung cancer?

Answer 137

Teaching and encouraging pursed-lip breathing.

Question 138

Which of the following interventions would be most appropriate for preventing urinary tract infections in an elderly female client?

Answer 138

Instruct the client to avoid tight-fitting pants.

Question 139

The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge to a 1-year-old but finds the I.V. has occluded. The nurse should:

Answer 139

Contact the prescriber to request an order change.

Question 140

A nurse writes a note in a client’s chart that says: “The physician is incompetent because he ordered the incorrect drug dosage.” This statement may lead to a charge of:

Answer 140

libel.

Question 141

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client’s care plan, which expected outcome should a nurse include?

Answer 141

Client will verbalize the intention to stop smoking.

Question 142

The nurse caring for a client who is receiving external beam radiation therapy for treatment of lung cancer should assess the client for which of the following?

Answer 142

Dysphagia.

Question 143

A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:

Answer 143

cryptorchidism.

Question 144

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?

Answer 144

C5

Question 145

A neonate born by cesarean delivery at 42 weeks’ gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following is the priority problem?

Answer 145

Hypoglycemia

Question 146

A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to:

Answer 146

Reassign the client to another nurse who is experienced in blood administration.

Question 147

When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to:

Answer 147

Develop respiratory infections easily.

Question 148

A physician has referred a client newly diagnosed with diabetes mellitus to the diabetes nurse-educator. When the nurse brings up the subject, the client states, “I’d rather work with you than with a stranger.” What is the nurse’s best response?

Answer 148

I’ll set up a meeting for today. Then you and I can meet to talk about how things went.

Question 149

A client has the leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?

Answer 149

Tingling of toes.

Question 150

The father of a U.S. Marine who was killed 2 days ago in Iraq is admitted after a serious suicide attempt. He is medically stable and has signed a no harm contract. During a talk with the nurse, he says, “Terrorism and war are holding me and the whole world hostage. It’s so unfair. I’d rather be dead than live alone in constant fear.” Which of the following nursing interventions are important in the next few days? Select all that apply.

Answer 150

• Discussing effective ways to express justifiable anger.
• Teaching stress management and relaxation techniques.
• Identifying community groups for relatives of military personnel.
• Strategizing about ways to increase a personal sense of security.

Question 151

The client who has a history of using angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which of the following responses by the nurse is most appropriate?

Answer 151

I will not continue to talk with you if you curse.

Question 152

In which areas of the United States is the incidence of tuberculosis highest?

Answer 152

Inner-city areas.

Question 153

A client had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client in residual limb care. Which of the following statements by the client indicates understanding of how to implement the plan of care?

Answer 153

I should rewrap the stump as often as needed.

Question 154

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is:

Answer 154

skin traction applied to a lower extremity, with the extremity suspended above the bed.

Question 155

An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 ml of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care?

Answer 155

Cover the client with warm blankets.

Question 156

Two weeks after a breastfeeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is “losing my breast milk. The baby had been nursing every 4 hours, but now she’s crying to be fed every 2 hours.” The nurse interprets the neonate’s behavior as most likely caused by which of the following?

Answer 156

The neonate’s temporary growth spurt, which requires more feedings.

Question 157

A client was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?

Answer 157

Continue suicide precautions.

Question 158

A client is trying to lose weight at a moderate pace. If the client eliminates 1,000 calories per day from his normal intake, how many pounds would the client lose in 1 week?

Answer 158

2

Question 159

A primiparous woman has recently delivered a term infant. Priority teaching for the patient includes information on:

Answer 159

Breastfeeding

Question 160

A client, now 37 weeks pregnant, calls the clinic because she’s concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to the client’s concerns, the nurse should take which action?

Answer 160

Explain that these are expected problems for the latter stages of pregnancy.

Question 161

The nurse applies which ethical principle when telling the truth to a client about the prognosis?

Answer 161

Veracity

Question 162

The nurse enters the room of a client who has just returned from the operating room after undergoing an incisional cholecystectomy. Which of the following would require prompt action by the nurse?

Answer 162

The client’s knee gatch is elevated on the bed.

Question 163

The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client?

Answer 163

Anesthesia/pain level assessment every 30 minutes.

Question 164

The nurse assesses an older adult for signs of dehydration. Which of the following findings would be consistent with a diagnosis of dehydration?

Answer 164

Orthostatic hypotension.

Question 165

The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.

Answer 165

• Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing).
• Notify the health care providers at the surgery center.
• Determine that there will be a latex-safe environment for surgery.

Question 166

A client is to start chemotherapy to treat lung cancer. A venous access device is placed to administer chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. Vital signs are BP 80/30, P 132, R 28, T 103 degrees F, and oxygen saturation 84%. The central line insertion site is inflamed. After calling the rapid response team, what should the nurse do next?

Answer 166

Insert a peripheral intravenous fluid line and infuse normal saline.

Question 167

A nurse calls the unit manager to report that her purse is missing from the locked break room. The nurse says that she thinks she knows which staff member stole the purse. Which of the following actions by the nurse manager would be appropriate? Select all that apply.

Answer 167

• Call hospital security to initiate an investigation.
• Ask the nurse to document all the facts related to the missing purse.
• Alert nursing administration that a staff member’s purse has been stolen.
• Ask other staff members to report any suspicious activity they may have observed.

Question 168

While performing a physical assessment on a term neonate shortly after birth, which of the following would cause the nurse to notify the primary health care provider?

Answer 168

Single crease on each of the palms.

Question 169

A client at 28 weeks’ gestation presents to the emergency department with a “splitting headache.” What actions are indicated by the nurse at this time? Select all that apply.

Answer 169

• Assess the client for vision changes or epigastric pain.
• Obtain a nonstress test.
• Assess the client’s reflexes and presence of clonus.

Question 170

During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?

Answer 170

Support the neonate’s head and back with the forearm.

Question 171

A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and occasionally drinks one or two beers. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruit or vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What behavioral changes should the nurse instruct the client to make to decrease her risk of cancer? Select all that apply.

Answer 171

• Improve nutrition.
• Use sunscreen.
• Stop smoking.
• Lose weight.

Question 172

The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrants prompt notification of the health care provider and a further plan of care?

Answer 172

Multigravida who had a positive oxytocin challenge test.

Question 173

The nurse should plan to begin rehabilitation efforts for the burn client:

Answer 173

After the client’s circulatory status has been stabilized.

Question 174

A nurse should question an order for a heating pad for a client who has:

Answer 174

active bleeding.

Question 175

The physician orders I.V. nalbuphine (Nubain) for a primigravid client in early active labor. After administering the drug, which of the following should the nurse do first?

Answer 175

Pull the side rails up.

Question 176

A client who tested positive for group B streptococcus has an order for 2 g ampicillin I.V. in 100 ml normal saline to be administered over 20 minutes. The nurse would set the infusion to run at how many drops per minute using tubing that delivers 10 drops/minute?

Answer 176

50

Question 177

A client is scheduled for cardiac catheterization the next morning. His physician ordered temazepam (Restoril), 30 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that:

Answer 177

sedatives reduce excitement; hypnotics induce sleep.

Question 178

A 2-month-old infant is brought to the clinic by his mother. His abdomen is distended, and he has been vomiting forcefully and with increasing frequency over the past 2 weeks. On examination, the nurse notes signs of dehydration and a palpable mass to the right of the umbilicus. Peristaltic waves are visible, moving from left to right. The nurse should suspect which condition?

Answer 178

Pyloric stenosis

Question 179

A physician orders acetaminophen (Tylenol) elixir, 160 mg every 4 hours, for a 14-month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?

Answer 179

None because this isn’t a safe dose

Question 180

A client with a genitourinary problem is being examined in the emergency department. When palpating the client’s kidneys, the nurse should keep in mind which anatomic fact?

Answer 180

The left kidney usually is slightly higher than the right one.

Question 181

A breastfeeding primiparous client asks the nurse how breast milk differs from cow’s milk. The nurse responds by saying that breast milk is higher in which of the following?

Answer 181

Fat.

Question 182

Two toddlers are arguing over a toy in the playroom. The nurse should say to the children:

Answer 182

Let me see if I can get both of you a similar toy.

Question 183

An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the client should the nurse interpret as most significant?

Answer 183

All of a sudden it doesn’t hurt at all.

Question 184

A client who has been diagnosed with osteoarthritis asks if he’ll eventually begin to notice deformities in his hands and fingers as the condition progresses. Which concept should the nurse include in her response?

Answer 184

Hand and finger deformities are associated with the development of rheumatoid arthritis.

Question 185

The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses’ notes of the chart for this client assessment?

Answer 185

Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup.

Question 186

After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which of the following nursing actions is most appropriate?

Answer 186

Sitting quietly with the client at the bedside until the medication takes effect.

Question 187

A nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Physiologic jaundice is caused by which characteristic?

Answer 187

Large, immature liver

Question 188

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders from the health care provider should the nurse verify before implementing?

Answer 188

Metoprolol (Lopressor) 5 mg IV push.

Question 189

The nurse notices that a client diagnosed with Major Depression and Social Phobia must get up and move to another area when someone sits next to her. Which of the following actions by the nurse is appropriate?

Answer 189

Convey awareness of the client’s anxiety about being around others.

Question 190

A client with ovarian cancer asks the nurse, “What is the cause of this cancer?” The most accurate response by the nurse is?

Answer 190

The risk of developing ovarian cancer is related to environmental, endocrine, and genetic factors.

Question 191

A nurse is monitoring a client who is having hallucinations. The nurse notes paranoid content in the client’s speech, and he appears agitated. The client is gesturing at a figure on the television. Which nursing interventions are appropriate? Select all that apply.

Answer 191

• Reinforce that the client isn’t in any danger.
• Acknowledge the presence of the hallucinations.
• Use a calm voice and simple commands.

Question 192

A nurse is reviewing a client’s chart and notes the Papanicolaou smear laboratory report indicates visualization of clue cells and a vaginal pH of 3.8. What should the nurse teach this client? Select all that apply.

Answer 192

• Seek care if experiencing thick, white, adherent vaginal discharge.
• Do not douche unless instructed by a health care provider.
• Seek care if the vaginal discharge has a fishy odor.

Question 193

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Answer 193

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.

Question 194

The nurse should assess a 26-year-old multigravida at 30 weeks’ gestation with premature rupture of the membranes for:

Answer 194

Foul-smelling amniotic fluid.

Question 195

Which of the following statements made by a mother of a 3-year-old child with unexplained injuries should the nurse determine as supportive of suspicions about abuse?

Answer 195

I’m disappointed that my child can’t tie his shoes.

Question 196

A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable?

Answer 196

250 mg every 6 hours

Question 197

A pregnant client is diagnosed with partial placenta previa. The nurse should prepare the client for:

Answer 197

Activity limited to bed rest.

Question 198

When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay pregnancy test, the nurse should tell the client which of the following about this test?

Answer 198

It has a high degree of accuracy within 1 week after ovulation.

Question 199

Which treatment is the best therapy for a stable client with digoxin toxicity?

Answer 199

Time and symptomatic treatment

Question 200

Which nursing intervention is most important when restraining a violent client?

Answer 200

Checking that the restraints have been applied correctly