All Clients Need (0601-0800)

Question 1

During a Preparation for Parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” The nurse should tell the participant which of the following about true labor contractions?

Answer 1

True labor contractions are felt first in the lower back, then the abdomen.

Question 2

A 14-month-old child has a severe diaper rash. Which of the following recommendations should the nurse provide to the parents?

Answer 2

Wash the buttocks using mild soap.

Question 3

A nurse is preparing to palpate a client’s thyroid gland. Which action by the nurse is appropriate?

Answer 3

Encircle the client’s neck with both hands, have the client slightly extend his neck, and ask him to swallow.

Question 4

A nurse observes that decerebrate posturing is a comatose client’s response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Answer 4

dysfunction in the brain stem.

Question 5

The primary goal in the plan of care for the client after cataract removal surgery is to:

Answer 5

Promote safety at home.

Question 6

Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed?

Answer 6

Nurses who are pregnant must wear gloves during administration of cytotoxic drugs.

Question 7

A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?

Answer 7

Respiratory isolation

Question 8

The client has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?

Answer 8

I don’t think about killing myself as much as I used to.

Question 9

A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis?

Answer 9

Sadness

Question 10

The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?

Answer 10

Sitting all afternoon in her room.

Question 11

A primigravid client visits the clinic at 12 weeks’ gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using:

Answer 11

Saline nose drops.

Question 12

Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following problems should receive the highest priority during the acute phase?

Answer 12

Ineffective breathing pattern related to neuromuscular impairment.

Question 13

A client with Alzheimer’s disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which of the following statements?

Answer 13

Dad said that what he missed most while he was here was using his aftershave.

Question 14

The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has:

Answer 14

Reduced intestinal peristalsis.

Question 15

When observing the client in a ritualistic pattern of behavior, the nurse should:

Answer 15

Allow the client to continue so that he will not become more anxious.

Question 16

When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client’s anxiety?

Answer 16

As a precaution, we wear gowns, goggles, and gloves to administer the medication.

Question 17

Which of the following is appropriate language development for an 8-month-old? The child should be:

Answer 17

Saying “dada” and “mama” nonspecifically.

Question 18

The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to:

Answer 18

Prevent dislocation of the prosthesis.

Question 19

After a bronchoscopy with biopsy, the nurse assesses the client. Which of the following signs should be reported immediately to the physician?

Answer 19

Laryngeal stridor.

Question 20

Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?

Answer 20

The operative incision is near the diaphragm.

Question 21

A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse’s priority intervention?

Answer 21

Discuss meals that include low-fat high-carbohydrate content.

Question 22

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

Answer 22

Providing a solution of viscous lidocaine for use as a mouth rinse

Question 23

A community health nurse is asked to consult with the family of a 4-year-old boy who is often disruptive at preschool, difficult to engage, and rarely speaks. When upset, the client flaps his arms and screeches. Which of the following questions and comments would be appropriate for the nurse to make to the parents? Select all that apply.

Answer 23

• “Has a pediatrician evaluated your child? He seems to have some abnormal behaviors for his age.”
• “How does your child behave at home? If you do not see acting-out behavior there, part of his problem may be dealing with new situations, such as school.”
• “How do you respond if he disobeys or acts out at home? If your techniques help prevent negative behavior, perhaps teachers can try similar measures at school.”

Question 24

A nurse is caring for a client 24 hours after an abdominal-perineal resection for a bowel tumor. The client’s wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?

Answer 24

Auscultate for bowel sounds.

Question 25

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Answer 25

Reduced cardiac output

Question 26

A client comes to the clinic for a routine checkup. To assess the client’s gag reflex, the nurse should use which method?

Answer 26

Place a tongue blade lightly on the posterior aspect of the pharynx.

Question 27

Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?

Answer 27

Auscultation of moist crackles.

Question 28

Which step should a nurse take first when administering a liquid medication to an infant?

Answer 28

Verify the physician order.

Question 29

A client chronically complains of being unappreciated and misunderstood by others. He is argumentative and sullen. He always blames others for his failure to complete work assignments. He expresses feelings of envy toward people he perceives as more fortunate. He voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?

Answer 29

Passive-aggressive personality

Question 30

The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?

Answer 30

Place the client in a private room.

Question 31

Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?

Answer 31

Temperature of 102° F (37.7° C)

Question 32

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care?

Answer 32

Increasing the need for antianxiety agents

Question 33

Which of the following would the nurse do after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Answer 33

Apply gentle pressure to the site with a sterile gauze pad.

Question 34

A multigravid client diagnosed with chronic hypertension is now in preterm labor at 34 weeks’ gestation. The primary health care provider has ordered magnesium sulfate at 3 grams/hour. Which assessment finding indicates that the intended therapeutic effect has occurred?

Answer 34

Decrease in the frequency and number of contractions.

Question 35

A client with bipolar disorder has been taking lithium carbonate (Lithonate), as prescribed, for the past 3 years. Family members have brought this client to the hospital. The client hasn’t slept, bathed, or changed clothes for 4 days; has lost 10 lb (4.5 kg) in the past month; and woke the entire family at 4 a.m. with plans to fly them to Hawaii for a vacation. Based on this information, the nurse understands that:

Answer 35

the client’s lithium level should be measured before he receives the next lithium dose.

Question 36

Sulfamethoxazole has been prescribed to treat a client’s urinary tract infection. The initial dosage is 2 g orally. The nurse has 500-mg tablets available. How many tablets should the nurse give?

Answer 36

4

Question 37

When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should recommend?

Answer 37

Take the prednisone with food.

Question 38

A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?

Answer 38

Apply deodorant only under the left arm.

Question 39

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information?

Answer 39

Lack of weight bearing causes demineralization of the long bones.

Question 40

A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, “When will I be able to eat three meals a day again like I used to?” Which of the following responses by the nurse is most appropriate?

Answer 40

Most clients can resume their normal meal patterns in about 6 to 12 months.

Question 41

The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan?

Answer 41

Increased risk for urinary tract infections.

Question 42

A client with a history of heart failure is receiving a lidocaine (Xylocaine) I.V. infusion at 2 mg/minute to treat runs of ventricular tachycardia. The client experiences hypotension, dyspnea, and irregular heartbeats. Which action can the nurse expect the physician to take first?

Answer 42

Decreasing the lidocaine infusion to 1 mg/minute

Question 43

A nurse is teaching a client about nonpharmacologic comfort measures to alleviate postoperative pain. Which client statement indicates a need for further teaching?

Answer 43

With patient-controlled analgesia, or PCA, I can control my pain by administering my own pain medication.

Question 44

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction?

Answer 44

Dystonia

Question 45

A client taking lithium is ordered citalopram (Celexa) for panic disorder. Five days after starting the citalopram, the client reports sweating and feelings of anxiety, restlessness, and confusion. The nurse suspects the client is experiencing:

Answer 45

serotonin syndrome.

Question 46

Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner?

Answer 46

Conduct a class for clients who require the same discharge teaching.

Question 47

The client is advised by the physician to have mammography screening annually. Measures to improve adherence with mammography screening include:

Answer 47

Making sure that the individual barriers to screening are minimized.

Question 48

A primipara calls the birthing unit 3 days after a vaginal delivery. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which of the following instructions would be appropriate?

Answer 48

Use ice packs for 20 minutes every 3 to 4 hours.

Question 49

A client who had a colectomy 8½ hours ago and has received 1,500 ml of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?

Answer 49

Dim the lights in the room.

Question 50

A client with obsessive-compulsive disorder follows a complicated bedtime routine that includes the use of a nightlight. A nurse notes this behavior in the care plan and passes on the information at change of shift. When the nurse returns the next day, the client states that she’s very upset because someone turned off her nightlight. When the nurse investigates, she finds that a newly hired nurse had cared for the client. What would be the nurse’s best course of action?

Answer 50

Ask the night nurse about her experience of caring for client the previous night.

Question 51

The nurse is caring for a client who has been placed on droplet precautions. Which of the following protective gear is required to take care of this client? Select all that apply.

Answer 51

• Surgical mask
• Gown
• Gloves
• Glasses

Question 52

A client who’s receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client’s discharge teaching plan? Select all that apply.

Answer 52

• Avoid crowded places such as shopping malls.
• Avoid people who have recently received attenuated vaccines.
• Wash hands frequently.
• Avoid activities that may cause bleeding

Question 53

A primigravid client who was successfully treated for preterm labor at 30 weeks’ gestation had a history of mild hyperthyroidism before becoming pregnant. The nurse should instruct the client to do which of the following?

Answer 53

Continue taking low-dose oral propylthiouracil (PTU) as ordered.

Question 54

The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which of the following views most perpetuates the stigma?

Answer 54

Clients can recover from mental illness if they have willpower.

Question 55

A nurse is performing a neurologic assessment on a neonate. Which sign is considered a normal finding in a neonate?

Answer 55

Positive Babinski’s reflex

Question 56

While caring for a post-term multigravida who is being induced with intravenous oxytocin (Pitocin) solution, which of the following findings should the nurse interpret as indicative of a possible complication?

Answer 56

Convulsions.

Question 57

During the initial stage of adaptation to the diagnosis of cancer and its treatment, the nurse can facilitate the client’s adaptation by:

Answer 57

Encouraging the client to maintain her usual role.

Question 58

According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal?

Answer 58

Improving the staff’s use of restraint procedures.

Question 59

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?

Answer 59

Maintaining traction continuously to ensure its effectiveness

Question 60

The nurse is taking care of a client who has an I.V. infusion pump. The pump alarm rings. What should the nurse do in order from first to last?

Answer 60

• Silence the pump alarm.
• Assess the client’s access site for infiltration or inflammation.
• Assess the tubing for hindrances to flow of solution.
• Determine if the infusion pump is plugged into an electrical outlet

Question 61

A client is receiving chemotherapy for brain cancer. When teaching the client and his wife about contamination from excretion of the chemotherapy drugs, the nurse should instruct the wife and client that:

Answer 61

Any contaminated linens should be washed separately and then washed a second time, if necessary.

Question 62

A nurse is caring for a child with leukemia. Which goal is a priority?

Answer 62

Monitoring the child’s temperature.

Question 63

Sequential compression therapy is to be used postoperatively on a client’s legs. The nurse must take which action first when the client returns to the room?

Answer 63

Confirm the client’s identity using two client identifiers.

Question 64

When assessing a child with muscular dystrophy, the nurse expects which finding?

Answer 64

Waddling gait

Question 65

The hospital where a client plans to give birth asks her to provide signed documents before delivery. The client asks the nurse to explain what an advance directive is. What is the nurse’s best response?

Answer 65

It’s a legal document that helps establish and verify your health care wishes in the event that you can’t speak for yourself or your infant.

Question 66

A 20-year-old obese primigravida at 40 weeks’ gestation is admitted to the birthing center in the first stage of labor with contractions lasting 50 seconds and occurring every 3 to 4 minutes. The client’s cervix is dilated 5 cm and is 75% effaced. When assessing the client’s emotional status, which of the following should the nurse anticipate the client to exhibit?

Answer 66

Seriousness.

Question 67

A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The primary health care provider prescribes treatment with risperidone (Risperdal) to improve the client’s negative and positive symptoms of schizophrenia. When evaluating the drug’s effectiveness on the client’s negative symptoms, the nurse should expect improvement in which of the following?

Answer 67

Apathy, affect, social isolation.

Question 68

Which nursing action is most appropriate in preventing an adverse reaction to total parenteral nutrition (TPN)?

Answer 68

Use an infusion pump to administer the TPN solution.

Question 69

A 10-year-old girl visits the clinic for a checkup before entering school. The child’s mother questions the nurse about what to expect of her daughter’s growth and development at this stage. Which response is appropriate?

Answer 69

Friends will be very important to her, and she’ll develop an interest in the opposite sex.

Question 70

A client with Buerger’s disease smokes two packs of cigarettes a day. Smoking cessation is critical or the client may lose the affected extremity. When helping a client change behavior, it is important to know the client’s:

Answer 70

Perception of the negative behavior.

Question 71

A nurse understands that for the parathyroid hormone to exert its effect, what must be present?

Answer 71

Adequate vitamin D level

Question 72

The guidelines for evaluating registered nurse professional conduct are contained in the:

Answer 72

Standards of Care.

Question 73

Which intervention should the nurse employ to reduce trauma caused during vaccine administration to a 6-month-old infant?

Answer 73

Simultaneously administer vaccines at separate sites.

Question 74

A nurse is preparing a staff education program about pulmonary circulation. Place the options below in the order that matches the path of pulmonary circulation. Use all options.

Answer 74

• Right ventricle
• Pulmonary artery
• Arterioles and alveoli
• Pulmonary vein
• Left atrium

Question 75

A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

Answer 75

The oxygen tubing is pinched.

Question 76

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client’s care?

Answer 76

Empty the urinary appliance when one-third full.

Question 77

While meeting with the nurse, a client’s wife states, “I don’t know what else to do to make him stop drinking.” The nurse should refer the wife to which of the following organizations?

Answer 77

Al-Anon.

Question 78

The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective?

Answer 78

Asocial behavior and anergia.

Question 79

An infant, age 6 weeks, is brought to the clinic for a well-baby visit. To assess the fontanels, how should the nurse position the infant?

Answer 79

Seated upright

Question 80

A client has a testicular nodule that is highly suspicious for testicular cancer. A laboratory test that supports this diagnosis is:

Answer 80

Increased AFP.

Question 81

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 81

Maintain current weight.

Question 82

A primigravid client at 8 weeks’ gestation tells the nurse that she doesn’t like milk. To ensure that the client consumes an adequate intake of milk products, the nurse should instruct the client that an 8-oz glass of milk is equal to which of the following?

Answer 82

1½ to 2 slices of presliced American cheese.

Question 83

A client is admitted to the oncology unit with an infection. It is suspected that the infection may be related to their vascular access device (VAD). The nurse should draw the blood cultures from which of the following sites?

Answer 83

A peripheral site and all lumens of the VAD.

Question 84

A nurse is providing dietary teaching for the parents of a child with celiac disease. Which statement by the parents indicates effective teaching?

Answer 84

Our child should avoid eating prepared puddings.

Question 85

A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. Which of the following responses by the nurse overhearing the conversation would be best?

Answer 85

Talking to the staff member privately about this.

Question 86

A client with chronic renal failure plans to receive a kidney transplant. Recently, the physician told the client that he is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, “I want to go off dialysis. I’d rather not live than be on this treatment for the rest of my life.” Which responses are appropriate? Select all that apply.

Answer 86

• Take a seat next to the client and sit quietly.
• Say to the client, “You’re feeling upset about the news you got about the transplant.

Question 87

Which factor should be checked when evaluating the effectiveness of an alpha-adrenergic blocker given to a client with benign prostatic hyperplasia (BPH)?

Answer 87

Voiding pattern

Question 88

Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?

Answer 88

Electrocardiogram (ECG).

Question 89

The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse’s best response?

Answer 89

Newborns typically move their whole body in response to pain.

Question 90

The nurse is discussing a treatment plan for mononucleosis with an adolescent. The nurse emphasizes that the client must:

Answer 90

Avoid contact sports and vigorous exercise for 2 to 4 weeks.

Question 91

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to:

Answer 91

a perinatologist.

Question 92

A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?

Answer 92

Protest.

Question 93

A multiparous client visits the urgent care center 5 days after a vaginal delivery experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, “Why am I continuing to bleed like this?” The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following?

Answer 93

Retained placental fragments.

Question 94

A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn’t harmed by the delay. Which action should the nurse take next?

Answer 94

The nurse should follow facility procedures for reporting an error.

Question 95

The nurse should warn a client who is taking a benzodiazepine about using which of the following medications in combination with his current medication?

Answer 95

Antacids.

Question 96

A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible?

Answer 96

Hypokalemia

Question 97

A client admitted to the unit with a diagnosis of end-stage renal disease is scheduled to undergo hemodialysis. He voices anxiety over shunt placement and management of care at home. A nurse initiates a referral to which members of the interdisciplinary team?

Answer 97

Home health nurse, nutritionist, and social worker

Question 98

A nurse admits a client who presents with symptoms of severe depression and a diagnosis of rapid cycling bipolar disorder. Several hours later, the client is pacing in the hall and asks the nurse to determine if he has a fever. His vital signs are: blood pressure of 148/90 mm Hg, pulse of 133 beats/minute, respirations of 24 breaths/minute, temperature of 99.2.° F (37.3° C). What do these assessment findings suggest?

Answer 98

The client needs further evaluation for illness.

Question 99

An extremely agitated client is brought to the psychiatric unit by her husband. He reports that she has been hospitalized several times for treatment of bipolar disorder and has spent thousands of dollars in the past week. The psychiatrist admits her to the unit for exacerbation of the manic phase of bipolar disorder. Which approach by the nurse promotes a therapeutic relationship with this client?

Answer 99

Maintaining a firm but nonthreatening manner

Question 100

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client’s arterial blood oxygen saturation?

Answer 100

Endotracheal suctioning

Question 101

Lomotil has been prescribed to treat a client’s diarrhea. The nurse should teach the client to report which of the following common side effects?

Answer 101

Urine retention.

Question 102

A primigravid client at 35 weeks’ gestation is scheduled for a biophysical profile. After instructing the client about the test, which of the following, if stated by the client as one of the parameters of this test, indicates effective teaching?

Answer 102

Amniotic fluid volume.

Question 103

The client with major depression and suicidal ideation has been taking bupropion (Wellbutrin) 100 mg P.O. four times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which of the following behaviors?

Answer 103

Suicide attempt.

Question 104

An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count 10,000/μl, hemoglobin 14.5 g/dl, hematocrit 40%, and the nontreponemal antibody test is positive. The nurse notifies the physician of the laboratory results. Which action by the nurse takes priority?

Answer 104

Consulting with the infection control nurse.

Question 105

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

Answer 105

Avoid stimulants and alcohol for 24 to 48 hours before the test.

Question 106

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/minute. The nurse should do which of the following in order from first to last?

Answer 106

• Affirm airway obstruction by the tube.
• Deflate the tube by cutting with bedside scissors.
• Remove the tube.
• Apply oxygen via face mask.

Question 107

In a small rural facility, a nurse is caring for a neonate born to a mother with diabetes mellitus. The neonate’s respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, and oxygen saturation is 92% on room air. The nurse obtains a blood glucose level, which is 50 mg/dl. Realizing the seriousness of the neonate’s condition, the pediatrician arranges transfer to a level III nursery. The social worker asks the nurse what transportation arrangements are needed. What type of transportation is required?

Answer 107

Medical helicopter sent to the rural facility from the level III facility

Question 108

To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day?

Answer 108

Prone.

Question 109

A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply.

Answer 109

• Interpretation of the fetal monitor strip.
• Support persons with the client.
• Prior delivery history.
• Amount of vaginal bleeding or discharge.
• Analgesia or anesthesia being used.

Question 110

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

Answer 110

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.

Question 111

A client with a cocaine dependency is irritable, anxious, highly sensitive to stimuli, and over-reactive to clients and staff on the unit. Which of the following actions is most therapeutic for this client?

Answer 111

Providing the client with frequent “time-outs.”

Question 112

The client’s wife asks the nurse whether the I.V. infusion is meeting her husband’s nutritional needs because he has vomited several times. The nurse’s response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:

Answer 112

170 calories.

Question 113

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which of the following?

Answer 113

Effects of analgesic medication.

Question 114

A preterm infant delivered 2 hours ago at 34 weeks’ gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?

Answer 114

Insertion of a chest tube into the neonate.

Question 115

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

Answer 115

Lubricant jelly

Question 116

The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:

Answer 116

A booster is recommended before college even if she had the vaccine a few years ago.

Question 117

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Answer 117

Use diaphragmatic breathing.

Question 118

A nurse is caring for a client with anorexia nervosa who has a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to dysfunctional eating patterns. Which interventions are supportive for this client? Select all that apply.

Answer 118

• Encourage the client to keep a journal.
• Provide small, frequent meals.
• Monitor the client during meals and for 1 hour after meals.
• Monitor weight gain.

Question 119

A client with anorexia nervosa describes herself as “a whale.” However, the nurse’s assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client’s unrealistic body image, which intervention should be included in the care plan?

Answer 119

Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep herself healthy

Question 120

A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child’s left leg is immobilized in a splint. What is an appropriate expected outcome for this child?

Answer 120

The child will change position with minimal discomfort.

Question 121

The client is admitted to the hospital for alcohol detoxification. Which of the following interventions should the nurse use? Select all that apply.

Answer 121

• Explaining to the client that the symptoms of withdrawal are temporary.
• Monitoring intake and output.
• Taking vital signs.
• Reinforcing reality if the client is disoriented or hallucinating.

Question 122

After teaching the mother of an 18-month-old child being discharged with a prescription for co-trimoxazole (Bactrim), which of the following statements by the mother would indicate the need for additional teaching?

Answer 122

I should give the medicine after he eats some food.

Question 123

When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize?

Answer 123

Diabetes mellitus

Question 124

The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which of the following indicates goals of therapy have been met?

Answer 124

Joint range of motion improved.

Question 125

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?

Answer 125

Latent phase

Question 126

Which of the following findings should the nurse note in the client who is in the compensatory stage of shock?

Answer 126

Tachycardia.

Question 127

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client’s legs are numb all the way up to the hips. The nurse should do which of the following next? Select all that apply.

Answer 127

• Notify the health care provider of the change.
• Place respiratory resuscitation equipment in the client’s room.
• Check for advancing levels of paresthesia.

Question 128

A client who’s 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:

Answer 128

9 to 12 weeks’ gestation.

Question 129

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has:

Answer 129

Decreased chest movement on the affected side.

Question 130

Which of the following assessments provides the best information about the client’s physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?

Answer 130

Vital signs.

Question 131

Using Abraham Maslow’s hierarchy of human needs, the nurse assigns highest priority to which client need?

Answer 131

Inserting a Foley catheter

Question 132

A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do?

Answer 132

Recommend he have his blood pressure rechecked within 2 weeks.

Question 133

The nurse is assessing a client with chronic pain. Which of the following is an expected response?

Answer 133

Normal vital signs, physical inactivity, and normal facial expressions.

Question 134

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply.

Answer 134

• Triage priority.
• Identifying information when possible (such as name, age, and address).
• Medications and treatments administered.

Question 135

The client is receiving 6 mg of selegiline transdermal system (Emsam) every 24 hours for major depression. The nurse should judge teaching about Emsam to be effective when the client makes which statement?

Answer 135

I need to avoid using the sauna at the gym.

Question 136

A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:

Answer 136

The antibiotic is the only medicine necessary.

Question 137

Which sign is an early indicator of heart failure in an infant with a congenital heart defect?

Answer 137

Tachycardia

Question 138

A 39-year-old multiparous client at 39 weeks’ gestation diagnosed with class II heart disease is admitted to the hospital in active labor. Which of the following should the nurse assess first after admission to the birthing area?

Answer 138

Contraction frequency and intensity.

Question 139

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:

Answer 139

Does not understand body integrity.

Question 140

A newly hired nurse on unit orientation prepares to administer vitamin K (AquaMEPHYTON) to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best?

Answer 140

Stop the nurse and have her reevaluate her injection techniques.

Question 141

In an initial screening for lead poisoning a 2-year-old child is found to have a lead level of 12 mcg/dl. The nurse should:

Answer 141

Educate parents on ways to reduce lead in the environment.

Question 142

A client who experienced long-term childhood sexual abuse by his babysitter and her boyfriend is diagnosed with post-traumatic stress disorder (PTSD). He is admitted for the second time after physically assaulting a prostitute. “She is no better that my babysitter and deserves to be dead. I’d like to kill the sitter, too.” With the knowledge of the client’s history and diagnosis, which of the following nursing interventions should be implemented at admission? Select all that apply.

Answer 142

• Institute precautions for suicide, assault, and escape.
• Ask the client to sign a “No Harm Contract.”
• Provide safe outlets for his anger and rage.
• In 1-to-1 staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend.

Question 143

The primary health care provider orders carbamazapine extended release (Tegretol-XR) for a client with a cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube, and carbamazapine is on the hospital’s “no crush” list. In order to administer the medication, the nurse should:

Answer 143

Contact the primary care provider to change the order.

Question 144

A woman in labor shouts to the nurse, “My baby is coming right now! I feel like I have to push!” An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for birth, which nursing intervention is most appropriate?

Answer 144

Applying gentle pressure to the baby’s head

Question 145

The nurse is to assess a neonate who was delivered vaginally about 12 hours ago. At which of the following times should the nurse anticipate performing the assessment?

Answer 145

Midway between feedings.

Question 146

Which characteristic is most common among suicidal clients?

Answer 146

Ambivalence

Question 147

When developing a teaching plan for a group of parents with preschoolers about the most effective strategies for safety, the nurse should tell the parents to focus on:

Answer 147

Modeling good examples of safe behavior.

Question 148

Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first?

Answer 148

What did the infant look like when you found him?

Question 149

An adolescent tells the nurse that he would like to lose weight and asks the nurse’s opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate?

Answer 149

Participating in an adolescent weight-reduction program.

Question 150

A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. His family members report that he has been confused for the last day. Which laboratory value is most likely responsible for this client’s symptoms?

Answer 150

Serum calcium level 13.8 mg/dl

Question 151

When instructing a pregnant client diagnosed with a chlamydial infection at 28 weeks’ gestation, which of the following should the nurse include about this infection during pregnancy?

Answer 151

She will likely receive a 10-day course of erythromycin.

Question 152

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client’s residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Answer 152

Incontinence and right-sided hemiparesis

Question 153

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN?

Answer 153

A 2-year-old child who nearly drowned 2 days earlier

Question 154

The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client’s arm to accomplish which of the following?

Answer 154

Distend the veins.

Question 155

Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual?

Answer 155

Paternalism

Question 156

Which of the following symptoms is common in clients with active tuberculosis?

Answer 156

Weight loss.

Question 157

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3?

Answer 157

Restrict staff and visitors with active infections.

Question 158

The nurse has just received morning change-of-shift report on four assigned clients. In what order from first to last should the nurse do the following?

Answer 158

• Notify the physician about a client with a serum potassium level of 6.2.
• Call the physician to request an antiemetic for a client who has been vomiting.
• Discuss the plan for the day with the nursing assistant, delegating duties as appropriate.
• Begin discharge paperwork for a client with a serum potassium level of 6.2.

Question 159

A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client’s fundus?

Answer 159

One fingerbreadth below the umbilicus

Question 160

A client with a history of hypertension and peripheral vascular disease underwent an aorto-bifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2 ° C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50-70 mL/hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends that the primary care provider:

Answer 160

Restarts the metoprolol.

Question 161

A community health nurse is working with disaster relief following a flood. Finding safe housing for survivors, providing support for families, organizing counseling, and securing physical care are examples of which type of prevention?

Answer 161

Tertiary prevention

Question 162

A client is receiving chrysotherapy (Myochrysine) as treatment for rheumatoid arthritis. The nurse should instruct the client to report?

Answer 162

Rash.

Question 163

A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has prescribed I.M. prostaglandin-F2a. After administration of the medication, the nurse should observe the client for which of the following?

Answer 163

Tachycardia.

Question 164

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Answer 164

Positioning the client on the side with the knees flexed

Question 165

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

Answer 165

use short, simple sentences.

Question 166

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?

Answer 166

Diabetes mellitus is more common in Hispanics and Blacks than in Whites.

Question 167

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which of the following? Select all that apply.

Answer 167

• Copious frothy mucus.
• Episodes of cyanosis.

Question 168

A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician orders cimetidine (Tagamet) I.V. Infusing this medication too rapidly may cause:

Answer 168

hypotension.

Question 169

An 8-year-old has a body mass index (BMI) for age at the 90th percentile, but has no other risk factors. The nurse should:

Answer 169

Refer the family to a dietician.

Question 170

Which statement describes the rationale for administering vitamin K to every neonate?

Answer 170

The neonate lacks intestinal flora to make the vitamin.

Question 171

A 16-year-old primigravid client admitted at 38 weeks’ gestation with severe preeclampsia is given intravenous magnesium sulfate and lactated Ringer’s solution. The nurse should obtain which of the following information?

Answer 171

Respiratory rate every hour.

Question 172

A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:

Answer 172

providing client education at every opportunity.

Question 173

A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, “It’s that school nurse again. She’s done nothing but try to make trouble for our family since my son started school. And now you’re in on it.” The nurse should respond by saying:

Answer 173

You sound pretty angry with the school nurse. Tell me what has happened.

Question 174

When magnesium sulfate is administered to a client in labor, its action occurs at which site?

Answer 174

Neural-muscular junctions

Question 175

When assessing a child with bronchiolitis, which finding does the nurse expect?

Answer 175

Productive cough

Question 176

A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, “There are poison crystals hidden in the showerhead. They’ll kill me if I take a shower.” Which nursing action is most appropriate?

Answer 176

Accepting these fears and allowing the client to take a sponge bath

Question 177

A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?

Answer 177

A new cast is needed every 1 to 2 weeks.

Question 178

While assessing a 2-month-old infant’s airway, the nurse finds that he isn’t breathing. After two unsuccessful attempts to establish an airway, the nurse should:

Answer 178

administer five back blows.

Question 179

A home care nurse is making a visit with a client who had a double-barrel colostomy created after bowel surgery. While the nurse is changing the client’s appliance, there is a knock on the door. The nurse answers the door. The client’s next-door neighbor wants to visit with the client. Which intervention by the nurse is most appropriate?

Answer 179

Ask the neighbor to come back in 20 minutes.

Question 180

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia?

Answer 180

Magnesium and potassium

Question 181

The client with Hodgkin’s disease develops B symptoms. These manifestations indicate which of the following?

Answer 181

The client has night sweats.

Question 182

A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which of the following requirements is not in place? Select all that apply.

Answer 182

• An I.V. line.
• Oxygen administration.
• An anesthesiologist.
• An identification band.

Question 183

Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant’s mother indicates understanding of the disease and its management? Select all that apply.

Answer 183

• “My baby can’t have milk-based formulas.”
• “We have to follow a strict phenylalanine diet.”
• “A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow.”

Question 184

A 10-year-old child who is 5’ 4” (138 cm) tall with a history of asthma uses an inhaled bronchodilator only when needed. He takes no other medications routinely. His best peak expiratory flow rate is 270 L/minute. The child’s current peak flow reading is 180 L/minute. The nurse interprets this reading as indicating which of the following?

Answer 184

The child needs to use a short-acting inhaled beta2-agonist medication.

Question 185

When preparing a 20-month-old with a foreign body in the nasal passage for removal of the foreign body by the health care provider, the nurse should apply a:

Answer 185

Papoose board.

Question 186

Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences:

Answer 186

heat intolerance and systolic hypertension.

Question 187

When performing an abdominal assessment, a nurse should follow which examination sequence?

Answer 187

Inspection, auscultation, percussion, and palpation

Question 188

A client is receiving methotrexate (Trexall), 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

Answer 188

Leucovorin (citrovorum factor or folinic acid)

Question 189

The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process?

Answer 189

You cannot have any visitors while you’re here involuntarily.

Question 190

The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?

Answer 190

Assist the client out of bed to sit upright in a chair for 1 hour.

Question 191

The nurse should conduct a focused assessment with the client with multiple sclerosis for the risk of which of the following? Select all that apply.

Answer 191

• Falls
• Skin breakdown
• Fatigue

Question 192

A 24-year-old woman is being assessed for a malformation of the uterus. The accompanying figure indicates which of the following uterine malformations?

Answer 192

Bicornate uterus.

Question 193

The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply.

Answer 193

• “Effects of the drug continue for 4 to 5 days after discontinuing the medication.”
• “I should have my blood levels tested periodically.”
• “Maximum dosage is not achieved until 3 to 4 days after starting the medication.”

Question 194

The nurse who uses self-disclosure should:

Answer 194

refocus on the client’s experience as quickly as possible.

Question 195

A nurse has custody of a client’s daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality?

Answer 195

• Shred the documents or place them in a Health Insurance
• Portability and Accountability Act (HIPAA) trash container.

Question 196

Jail staff asked for a mental health evaluation on a 21-year-old woman. The client was arrested on charges of prostitution; the request for evaluation followed after the client stabbed herself repeatedly with a fork. The evaluation revealed that she was kidnapped and held from ages 8 to 16 by a convicted child pornographer. The client said she never contacted her family after her release from captivity. The nurse should do the following in what order of priority from first to last.

Answer 196

• Initiate suicide precautions and a no-harm contract.
• Offer empathy and support; be nonjudgmental and honest with her.
• Encourage safe verbalizations of her emotions, especially anger.
• Ask the client if she wishes to contact her family while hospitalized.

Question 197

If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do which of the following?

Answer 197

Sit in a tub of warm water.

Question 198

A client is admitted to the emergency department with sudden onset of chest pain. Which of the following orders should the nurse implement immediately? Select all that apply.

Answer 198

• Administer nitroglycerin.
• Administer aspirin.
• Administer morphine.
• Provide oxygen.

Question 199

The physician prescribes raloxifene hydrochloride (Evista) for a 60-year-old woman. The drug is effective if the client does not have:

Answer 199

Osteoporosis.

Question 200

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?

Answer 200

Deficient fluid volume related to osmotic diuresis