All Clients Need (0801-1000)

Question 1

Which of the following outcomes should the nurse include in the initial plan of care for a client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and unresponsiveness to the nurse’s questions?

Answer 1

The client will interact with the nurse.

Question 2

When the open method is used for treating burns, which of the following actions should the nurse take to help prevent discomfort caused by air currents over the client’s burned skin surfaces?

Answer 2

Support the bed linens on a cradle.

Question 3

A client with cirrhosis should be encouraged to follow which diet?

Answer 3

Well-balanced normal nutrients, low-sodium diet.

Question 4

A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?

Answer 4

Playing with the child every day.

Question 5

The nurse is reviewing the chart of a 55-year-old male client who is scheduled for a lumbar laminectomy. The nurse should report which of the following to the surgeon?

Answer 5

Pimple on the lower back.

Question 6

A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:

Answer 6

Bowel regimen.

Question 7

An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?

Answer 7

Deficient knowledge (disease process and treatment regimen)

Question 8

When developing appropriate short-term goals with clients who are inpatients, which of the following is most realistic?

Answer 8

The client will write a list of strengths and needs.

Question 9

Four months ago, the son and daughter of a client who was in a vegetative state gave consent for a feeding tube and agreed to long-term care placement. Nurses in the long-term care facility note that the son and daughter have recently become more distraught over their mother’s condition. One day while visiting together, the son and daughter approach the nurse about having the feeding tube removed. Which statement by the nurse best explains the legal rights of individuals in this situation?

Answer 9

Legally, there are no time constraints on previous decisions made.

Question 10

A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:

Answer 10

hold and rock him and give him a security object.

Question 11

Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested?

Answer 11

Ketoconazole suppresses adrenal steroid secretion.

Question 12

The charge nurse on an antepartal unit is making staffing assignments for the day. There is an RN, licensed practical nurse (LPN), and an unlicensed personnel (UAP) to care for 25 patients. The nurse should assign which of the following clients to the LPN?

Answer 12

A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4-6 hours prn while awaiting urine cultures to be returned.

Question 13

A 19-year-old unmarried college student is approximately 8 weeks pregnant asks the nurse, “If I have an abortion in the next 2 or 3 weeks, how will it be done?” The nurse instructs the client that at this gestational age an abortion is usually performed by which of the following techniques?

Answer 13

Dilatation and curettage.

Question 14

While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client’s family how to deal with it at home, what should the nurse do?

Answer 14

Irrigate the tube with cola.

Question 15

A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:

Answer 15

Wait until the father arrives.

Question 16

A female client who has a urinary diversion tells the nurse, “This urinary pouch is embarrassing. Everyone will know that I’m not normal. I don’t see how I can go out in public anymore.” The most appropriate nursing goal for this client is to:

Answer 16

Express fears about the urinary diversion.

Question 17

Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?

Answer 17

Ask the client to identify other situations in which he demonstrated responsibility for himself.

Question 18

The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the accompanying chart and compares these findings to the Apgar score obtained at birth, also found in the chart. What should the nurse do next?

Answer 18

Continue to assess the neonate.

Question 19

When developing the discharge teaching plan for a child with chronic renal failure and the family, the nurse should emphasize restriction of which of the following nutrients?

Answer 19

Phosphorus.

Question 20

The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be most appropriate for this client?

Answer 20

Ask the client’s spouse to supervise the daily administration of the medications.

Question 21

A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and doesn’t respond to verbal or tactile stimuli. In formulating nursing care interventions, the nurse should give priority to:

Answer 21

observing and evaluating the client’s nutritional needs.

Question 22

Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term?

Answer 22

Sole creases covering the entire foot.

Question 23

The mother of a 3-year-old child tells the nurse her child is “fussy” and not as “easy going” as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:

Answer 23

Provide structured feeding times and routines.

Question 24

Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?

Answer 24

Absence of tear formation.

Question 25

The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?

Answer 25

Rebound hypoglycemia.

Question 26

After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:

Answer 26

Take thyroxine replacement for the remainder of the client’s life.

Question 27

An 18-year-old tells the nurse, “Everyone does it, so it’s all right,” to justify rule-breaking behavior. The nurse realizes this is an example of which level or stage of moral reasoning development as described by Kohlberg?

Answer 27

Conventional.

Question 28

A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply.

Answer 28

• T-wave inversion
• ST-segment elevation
• Pathologic Q-wave

Question 29

An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which of the following actions should the school nurse do ?

Answer 29

Move the adolescent to a cool environment.

Question 30

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors is most likely of greatest significance in causing an exacerbation of ulcerative colitis?

Answer 30

A demanding and stressful job.

Question 31

A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for:

Answer 31

Focal ischemia.

Question 32

An elderly client hospitalized 4 days for treatment of acute respiratory distress has become confused and disoriented. The client has been picking invisible items from blankets and yelling at a daughter who is not in the room. The family tells the nurse that the client has been treated for anxiety with Xanax (alprazolam) for years, but Xanax is not part of the client’s current medication list. Which of the following safety measures should be implemented? Select all that apply.

Answer 32

• The client’s medical and mental status will be evaluated frequently and treated as needed.
• Medications will be made available to help with the hallucinations.
• The client will be placed on withdrawal precautions and treatment immediately.

Question 33

A nurse is giving instructions to a client with a new colostomy. The client states, “I am so tired today; I just cannot think.” The nurse should:

Answer 33

Reschedule the appointment at a time when the client is rested.

Question 34

Eardrops have been prescribed to be instilled in the adult client’s left ear to soften cerumen. To position the client, the nurse must do which of the following? Select all that apply.

Answer 34

• Straighten the client’s eustachian tube.
• Gently pull the auricle up and back.

Question 35

A client comes to a community mental health clinic for a psychiatric evaluation at his family’s request. During the initial interview, the client tells the nurse about painting the streets to beautify the city, lecturing subway riders about germ control, and banning smoking in order to clean up the environment. The client is irritable and easily distracted by the slightest sound. Which stage of mania is the client exhibiting?

Answer 35

Acute mania

Question 36

Which client statement indicates that the client has coped effectively with a relationship problem?

Answer 36

We are really listening to each other about our different view on issues.

Question 37

A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should:

Answer 37

Keep the client tobacco-free for 30 minutes before the test.

Question 38

A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast care, the nurse should?

Answer 38

Use only the palms of the hand when handling the cast.

Question 39

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test?

Answer 39

Total protein

Question 40

The client who is receiving chemotherapy is not eating well but otherwise feels healthy. Which meal suggestion would be best for this client?

Answer 40

Broiled chicken, green beans, and cottage cheese.

Question 41

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands:

Answer 41

the client must take benztropine (Cogentin) as ordered to prevent a return of symptoms.

Question 42

The primary health care provider has ordered intravenous mannitol (Osmitrol) for a child with a head injury. The best indicator that the drug has been effective is:

Answer 42

Decreased intracranial pressure.

Question 43

A female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She’s placed on trimethoprim-sulfamethoxazole (Bactrim) to treat the infection. Another medication is ordered to decrease the pain and frequency. Which is the most likely medication ordered for the pain?

Answer 43

Phenazopyridine (Pyridium)

Question 44

While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client’s cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first?

Answer 44

Note the color, amount, and odor of the amniotic fluid.

Question 45

The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation?

Answer 45

Airborne precautions.

Question 46

A client is to be discharged from an alcohol rehabilitation program. Which of the following should the nurse emphasize in the discharge plan as a priority?

Answer 46

Follow-up care.

Question 47

One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse is most therapeutic?

Answer 47

Your behavior is disturbing to the other clients. I’ll walk with you around the patio to help you release some of your energy.

Question 48

The nurse is planning to teach incisional care to a client before discharge. Which of the following instructions should be included?

Answer 48

Do not be concerned about uneven lumps under the suture lines.

Question 49

A nurse must assess a client’s judgment to determine his mental status. To best accomplish this, the nurse should have the client:

Answer 49

discuss hypothetical ethical situations.

Question 50

Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy?

Answer 50

a compromised skin graft.

Question 51

A young man makes an appointment to see the psychiatric nurse at the Employee Assistance Program of a large corporation beacuse his female boss is sending him provocative e-mails, and making seductive remarks on his voice mail at home. The nurse informs him about Corporate Workplace Violence Guidelines and he agrees to work with Corporate Security on the issue. What should the nurse do next?

Answer 51

Ask the client about his reactions to this situation.

Question 52

The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse’s first step in planning the dietary instructions?

Answer 52

Assess the family’s food preferences.

Question 53

The nurse is preparing to assist with the removal of a chest tube. Which of the following is appropriate at the site from which the chest tube is removed?

Answer 53

Petroleum gauze.

Question 54

When planning home care for a 3-year-old child with eczema, what should the nurse teach the mother to remove from the child’s environment at home?

Answer 54

Stuffed animals.

Question 55

In the oliguric phase of acute renal failure, the nurse should assess the client for:

Answer 55

Pulmonary edema.

Question 56

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?

Answer 56

They increase the need for insulin.

Question 57

The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next:

Answer 57

Check the dressing for signs of bleeding.

Question 58

The nurse prepares to discharge a 5-year-old child from the 1-day surgery unit. The nurse leaves the room to get supplies and then, on returning, finds that the child is not breathing. The client is pulseless, and the nurse begins chest compressions. The nurse should apply pressure:

Answer 58

On the lower sternum with the heel of one hand.

Question 59

When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse should place the first priority on discussing the use of which of the following?

Answer 59

Child restraints in automobiles.

Question 60

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is:

Answer 60

weight.

Question 61

An anticipated outcome for the client after cataract removal surgery would include which of the following?

Answer 61

The client describes methods to prevent an increase in intraocular pressure.

Question 62

A physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guérin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:

Answer 62

hematuria.

Question 63

Which of the following is an early sign of laryngeal cancer?

Answer 63

Persistent mild hoarseness.

Question 64

A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis?

Answer 64

Tachycardia

Question 65

A 17-year-old client visits the clinic at 36 weeks’ gestation. The client’s blood pressure is 130/90 mm Hg. On previous visits, her blood pressure ranged from 100 to 110 mm Hg systolic, 70 to 80 mm Hg diastolic. Further assessment reveals slight edema of her hands and 1 + proteinuria. The nurse anticipates that the physician will most likely order which of the following?

Answer 65

Bed rest with bathroom privileges.

Question 66

When an infant with pyloric stenosis is admitted to the hospital, which of the following should the nurse do first?

Answer 66

Weigh the infant.

Question 67

A primigravid client at 30 weeks’ gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client’s:

Answer 67

Temperature.

Question 68

A nurse completing her management rotation in the intensive care unit (ICU) is working with an experienced ICU nurse. One client’s work supervisor calls to “check up” on the client. The nurse offers to transfer the call to the client’s family members. The experienced ICU nurse recognizes this action as:

Answer 68

protection of the client’s privacy.

Question 69

A nurse is preparing to administer 500 ml of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/ml. At what rate should the nurse infuse the solution?

Answer 69

42

Question 70

Which of the following positions would be most comfortable for a client with a ruptured disc at L5-S1 right?

Answer 70

Supine with the legs flexed.

Question 71

An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?

Answer 71

Gown, gloves, mask, and eye goggles or eye shield

Question 72

A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:

Answer 72

Bence Jones protein in the urine

Question 73

A 13-month-old has a febrile seizure one month after the administration of the chicken pox vaccine. The nurse should:

Answer 73

Report the event through the CDC Vaccine Adverse Event Reporting System.

Question 74

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?

Answer 74

Assess vital signs.

Question 75

A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The primary health care provider orders manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this order based on the understanding that this action will accomplish which of the following?

Answer 75

Decrease intracranial pressure.

Question 76

A client with terminal cancer tells the nurse that she is not afraid to die and she is thinking about how to plan her funeral. The most appropriate referral the nurse could suggest would be to the:

Answer 76

Pastoral care department.

Question 77

Which of the following philosophies should the nurse most likely integrate into the plan of care for a client and family to help them best cope during the final stages of the client’s illness?

Answer 77

Living each day as it comes as fully as possible.

Question 78

A 12-year-old client says, “Give me my pajamas. I’m not putting your silly gown on.” An appropriate response by the nurse should be:

Answer 78

You’re upset because you feel awkward and embarrassed in these gowns.

Question 79

The nurse has discussed sexuality issues during the prenatal period with a primigravida who is at 32 weeks’ gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says:

Answer 79

“I should not get sexually aroused or have any nipple stimulation.”

Question 80

A 70-year-old, previously well client asks the nurse, “I notice I have tremors. Is this just normal for my age?” The best response for the nurse to make is which of the following?

Answer 80

You should report this to the physician because it may indicate a problem.

Question 81

When developing the teaching plan for a primipara and her term neonate, on the first postpartum day the nurse plans to discuss neonatal reflexes. After describing the rooting reflex, which of the following, if stated by the mother as the age at which the reflex disappears, indicates effective teaching?

Answer 81

3 to 4 months.

Question 82

A 76-year-old client tells the nurse that she has lived long and does not need mammograms. Which is the nurse’s best response?

Answer 82

The incidence of breast cancer increases with age.

Question 83

A client undergoing long-term peritoneal dialysis at home is currently experiencing reduced outflow from the dialysis catheter. To determine if the catheter is obstructed, the nurse should inquire whether the client has:

Answer 83

Constipation

Question 84

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:

Answer 84

fluid replacement.

Question 85

An older adult has chest pain and shortness of breath. The health care provider prescribes nitroglycerin tablets. Which should the nurse instruct the client to do?

Answer 85

Put the tablet under the tongue until it is absorbed.

Question 86

A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first:

Answer 86

Assist the client up to the toilet to attempt to void.

Question 87

A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply.

Answer 87

• Rash.
• Hyperthermia.
• Muscle rigidity.

Question 88

The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see figure). The nurse should

Answer 88

Proceed to suction the client’s tracheostomy.

Question 89

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the the UAP reports which of the following about one of the clients?

Answer 89

Evidence of spontaneous rupture of the membranes.

Question 90

A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he’s scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next?

Answer 90

Apply physical restraints to protect the client, then contact the physician for orders.

Question 91

A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through:

Answer 91

inhalation of aerosols.

Question 92

A nurse is assessing a neonate. Which finding suggests hypothermia?

Answer 92

Bradycardia

Question 93

A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider?

Answer 93

Give 1 to 3 teaspoons of fluid every 10 to 15 minutes.

Question 94

Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents? Select all that apply.

Answer 94

• Abdominal pain.
• Blood in the stool.
• Reduced blood clotting ability

Question 95

A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:

Answer 95

has type 2 diabetes.

Question 96

In response to the nurse’s question about how a postpartum client is feeling, the client replies that she is tired, sore, and hungry. She then begins to relate her birth experience. Based on these data, the nurse determines that the client is in which phase of postpartal psychological adaptation?

Answer 96

Taking in.

Question 97

A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size?

Answer 97

23G

Question 98

While caring for a multigravid client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?

Answer 98

Yogurt.

Question 99

The nurse is teaching a client with Parkinson’s disease about the nutritional modifications to make in the diet because the client is taking levodopa. The nurse should instruct the client to?

Answer 99

Avoid foods high in pyridoxine (vitamin B12).

Question 100

Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which of the following adverse effects of this medication?

Answer 100

Maculopapular rash.

Question 101

When a client wants to read the chart, the nurse should:

Answer 101

Give the client the chart and answer questions for him.

Question 102

A nurse is reviewing a care plan for a 10-year-old child who has recently been diagnosed with type 1 diabetes. Which instruction should the nurse remove from a teaching plan focusing on proper hygiene?

Answer 102

Teach blood glucose monitoring.

Question 103

The most important long-term goal for a client with hypertension is to:

Answer 103

Make a commitment to long-term therapy.

Question 104

A client with Parkinson’s disease visits the physician’s office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg P.O. daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?

Answer 104

I take the medication at bedtime.

Question 105

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:

Answer 105

pulmonary crackles.

Question 106

When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?

Answer 106

Dressing.

Question 107

When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply.

Answer 107

• Child molesters pick those over whom they have some authority, making it easier for them to manipulate the child with special favors or attention.
• Child molesters gain a child’s trust before making sexual advances so the child feels obligated to comply with sex.
• Child molesters often choose victims whose parents must work long hours, making the extra attention initially welcome by the child.
• Child molesters maintain the secrecy of their actions by threatening the child if offering attention and favors fail or if the child is close to revealing the secret.

Question 108

During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse’s best response?

Answer 108

8 days after conception.

Question 109

The nurse reports to the primary health care provider signs of increased intracranial pressure in an infant with a myelomeningocele who has which of the following?

Answer 109

A high-pitched cry.

Question 110

When auscultating a client’s abdomen, a nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:

Answer 110

nothing abnormal.

Question 111

A clinic client with agoraphobia must go to a local laboratory to have blood drawn. The client is terrified, stating, “I know I can’t handle being in the waiting room.” What is the nurse’s most therapeutic response?

Answer 111

I’ll arrange for you to be the first client and we’ll talk about it afterward.

Question 112

A client with a diagnosis of borderline personality disorder has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at the weekly conference. Which intervention is most appropriate for the nursing staff to implement?

Answer 112

Rotate the nurses who are assigned to the client.

Question 113

In providing discharge teaching for the client after a modified radical mastectomy, the nurse should instruct the client to avoid which of the following activities?

Answer 113

Working in her rose garden.

Question 114

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse’s instructions when he states he will:

Answer 114

Lose weight.

Question 115

A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?

Answer 115

Medication therapy.

Question 116

When planning care for a client with viral hepatitis, the nurse should review labororatory reports for which of the following abnormal laboratory values?

Answer 116

Prolonged prothrombin time.

Question 117

A nurse is administering oxytocin (Pitocin) to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client’s care plan?

Answer 117

strict monitoring of intake and output.

Question 118

A 45-year-old client with colon cancer states, “I don’t want any treatment. I haven’t seen any family members in 25 years. I’m a loner. Besides, I’ll decide when and how I want to die.” In which order of priority from first to last should the nurse do the following?

Answer 118

• Ask the client about thoughts of suicide.
• Ask the client what methods of suicide are available.
• Express concern for the client’s feelings and safety.
• Tell the client that the primary care provider will ask for a psychiatric consult.

Question 119

The nurse is making a follow-up telephone call to a 52-year-old client with lung cancer. The client now has a low-grade fever (100.6° F [38.1° C]), nonproductive cough, and increasing fatigue. The client completed the radiation therapy to the mass in the right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. The nurse should advise the client to:

Answer 119

To contact the physician for an appointment today.

Question 120

During the clinical breast examination, which of the following is a normal finding?

Answer 120

Long-term, bilateral nipple inversion.

Question 121

Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which instruction?

Answer 121

Use sunscreen whenever going outside.

Question 122

Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?

Answer 122

Continue the lithium and reassure the client that these temporary side effects will subside.

Question 123

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client?

Answer 123

Nitroprusside

Question 124

The night nurse has completed a change-of-shift report. The day nurse making rounds notes that a postpartum client receiving magnesium sulfate has developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below ordered. In addition to adjusting the infusion rate and notifying the primary health care provider, which of the following actions by the day nurse is most important?

Answer 124

Complete an incident report.

Question 125

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child’s condition, the nurse should ask the parents:

Answer 125

Do you give the baby a bottle to take to bed?

Question 126

A clinical nurse specialist developed clinical pathways for common orthopedic conditions. The interdisciplinary team uses these pathways to:

Answer 126

provide a care plan for caregivers to ensure continuity of care.

Question 127

A dilatation and curettage (D&C;) is scheduled for a primigravid client admitted to the hospital at 10 weeks’ gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which of the following feelings?

Answer 127

Guilt.

Question 128

To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?

Answer 128

The client receives a complete bed bath each morning.

Question 129

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug’s adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?

Answer 129

When my moods fluctuate, I’ll increase my dose of lithium.

Question 130

A nurse is planning care for a client with human immunodeficiency virus (HIV). She’s being assisted by a licensed practical nurse (LPN). Which statements by the LPN indicate her understanding of HIV transmission? Select all that apply.

Answer 130

• “I’ll wear a mask, gown, and gloves when splashing of body fluids is likely.”
• “I’ll wash my hands after client care.”

Question 131

A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client’s nursing care plan? Select all that apply.

Answer 131

• “Use pressure-reduction devices.”
• “Reposition every 1 to 2 hours.”
• “Teach the family how to care for the wound.”
• “Clean the area around the ulcer with mild soap.”

Question 132

A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?

Answer 132

Report back to the nurse immediately if any client has an output less than 240 ml.

Question 133

A nurse should determine a child’s body surface area by using:

Answer 133

a nomogram.

Question 134

A laboring client at –2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:

Answer 134

Place gentle pressure upward on the fetal head.

Question 135

A client in labor has an episiotomy. The nurse understands that the client is at risk for which complication?

Answer 135

Prolonged dyspareunia

Question 136

When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which of the following? Select all that apply.

Answer 136

• Decreased muscle tone
• Decreased respirations

Question 137

A client with schizophrenia tells a nurse preparing him for discharge that he has no home or family and has been living on the street. Which action is most appropriate?

Answer 137

Asking the physician to refer the client to social services for further evaluation

Question 138

The nurse manager on a pediatric floor is reviewing national sentinel event alerts and preparing recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply.

Answer 138

• Utilize only oral syringes to administer oral medication.
• Limit the size of IV fluid bags that can be hung on small children.
• Reduce the available concentrations or dose strengths of high alert medications to the minimum.

Question 139

The client has various sensory impairments associated with diabetic disease. The nurse determines that the client needs further instruction when he states which of the following?

Answer 139

I’ll avoid kitchen activities.

Question 140

What should the nurse teach the client to do to prevent stress incontinence? Select all that apply.

Answer 140

• Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises.
• Avoid dietary irritants (e.g., caffeine, alcoholic beverages).

Question 141

During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, “I can’t gain weight. I’m fat enough as it is. I’ll be really disgusting if I get fatter.” When responding to this client, which response by the nurse would be most therapeutic?

Answer 141

Use nonjudgmental and realistic comments.

Question 142

During a visit to the clinic, a mother who’s breast-feeding her 2-month-old infant expresses concern over the infant’s bowel movements. Which statement by the mother would lead the nurse to believe that the infant’s bowel movements are normal?

Answer 142

The baby’s stools are bright yellow and soft.

Question 143

The nurse is assessing a client who has a chronic mental illness. Which of the following are early signs of relapse? Select all that apply.

Answer 143

• Decrease in sleep and self-care.
• Increase in social isolation and withdrawal.
• More fears and suspiciousness.

Question 144

Which of the following groups would benefit most from education regarding potential risk factors for melanoma?

Answer 144

Parents with children.

Question 145

When caring for a client who’s being treated for hyperthyroidism, the nurse should:

Answer 145

balance the client’s periods of activity and rest.

Question 146

The physician has determined that a primigravid client in active labor requires a cesarean delivery because of cephalopelvic disproportion. After the delivery of a male neonate, for which of the following should the nurse assess first?

Answer 146

Nasopharyngeal secretions.

Question 147

A client has been placed on isoniazid (INH) as prophylactic treatment against tuberculosis. Which of the following instructions should the nurse plan to include in the client’s teaching plan about taking isoniazid?

Answer 147

The client should limit tyramine-rich foods in the diet.

Question 148

A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses’ station and begins reading the client’s chart. The staff nurse questions the director about reading the client’s chart. The director states that the client is her neighbor’s son. What action should the nurse take to protect the client’s right to privacy?

Answer 148

Inform the nurse director she’s violating the client’s right to privacy and ask her to return the chart.

Question 149

A neonate is to receive an I.V. infusion of normal saline solution at 3 ml/hour. The nurse is setting the alarms on an I.V. infusion pump. How should the nurse set the alarms?

Answer 149

At 5% above and 5% below the keep-vein-open rate.

Question 150

A 22-year-old client loses her fiancé in a drunk-driving accident. She complains of difficulty eating, sleeping, and working. Her reaction is considered:

Answer 150

a crisis caused by traumatic stress.

Question 151

A mute client begins to express herself verbally on occasion. Which of the following nursing actions should be credited with helping a mute client express herself verbally?

Answer 151

Making open-ended statements followed with silence.

Question 152

A 62-year-old client with a 29-pack per year history is admitted with a diagnosis of lung cancer. She reports having “no appetite” and exhibits symptoms of anorexia. The client is 5 feet, 8 inches tall and weighs 112 lb. The client is now scheduled for a left lung lobectomy. Which of the following increases the client’s risk of developing postoperative pulmonary complications?

Answer 152

The client is 5 feet, 8 inches tall and weighs 112 lb.

Question 153

A 6 month old is taken to the pediatrician, and the mother states that the child is not growing like other 6 month olds in families whom she knows. The birth weight of the child was 7 pounds 11 ounces, and the current weight is 11 pounds 2 ounces. The nurse would instruct the client that:

Answer 153

The child is underweight and needs a dietary assessment.

Question 154

The nurse is assessing fetal position for a 32-year-old client in her eighth month of pregnancy. As shown below, the fetal position can be described as which of the following?

Answer 154

Left occipital transverse.

Question 155

A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks’ gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is:

Answer 155

4

Question 156

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse’s first response?

Answer 156

Notify the anesthesiologist.

Question 157

A client is diagnosed with oligohydramnios during a clinic visit. Before the client gives birth, the nurse should notify the nurses working in the nursery about the diagnosis so they are aware of which complication that’s commonly associated with oligohydramnios?

Answer 157

Renal malformations

Question 158

A child, age 5, with an intelligence quotient (IQ) of 65 is admitted to the facility for evaluation. When planning care, the nurse should keep in mind that this child:

Answer 158

would have a diagnosis of mild mental retardation.

Question 159

A 62-year-old woman thinks her husband’s rehabilitation needs have been unmet by his employer after his diagnosis and treatment of colon cancer. The nurse should give her information about:

Answer 159

The Americans With Disabilities Act of 1990.

Question 160

To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?

Answer 160

Decrease the carbohydrate content of meals.

Question 161

While reviewing a client’s chart, the nurse notices that the client has myasthenia gravis. Which statement about neuromuscular blocking agents is true for a client with this condition?

Answer 161

Pancuronium and succinylcholine both require cautious administration.

Question 162

A client with the nursing diagnosis of Fear, related to being embarrassed in the presence of others, exhibits symptoms of social phobia. What should the goals be for this client? Select all that apply.

Answer 162

• Manage his fear in group situations.
• Verbalize feelings that occur in stressful situations.
• Develop a plan for responding to stressful situations.

Question 163

The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates:

Answer 163

Urine retention.

Question 164

A female client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting?

Answer 164

Denial

Question 165

Following the formation of an ileal conduit, the nurse notes that the client’s urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data?

Answer 165

These findings are normal for a client with an ileal conduit.

Question 166

A client is scheduled for urinary diversion surgery to treat bladder cancer. Before surgery, the health care team — consisting of a nurse, dietitian, social worker, enterostomal therapist, surgeon, client educator, and mental health worker — meets with the client. After the meeting, the client states, “My life won’t ever be the same. What am I going to do?” Which health care team member should the nurse consult to help with the client’s concerns?

Answer 166

Client educator

Question 167

When monitoring a client recently admitted for treatment of cocaine addiction, a nurse notes sudden increases in the arterial blood pressure and heart rate. Which medication should the nurse prepare to administer?

Answer 167

Nifedipine (Procardia)

Question 168

The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which of the following parameters is not necessary every 15 minutes during the first postoperative hour?

Answer 168

Urine output.

Question 169

A client who’s 3 months pregnant with her first child reports that she has had increasing morning sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal heart tones. The nurse should suspect which complication of pregnancy?

Answer 169

Gestational trophoblastic disease

Question 170

Which nursing action is essential when providing continuous enteral feeding?

Answer 170

Elevating the head of the bed

Question 171

A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because:

Answer 171

they contain high levels of phenylalanine.

Question 172

Which change does a nurse demonstrate when she helps a young mother adjust to the birth of her child?

Answer 172

Situational

Question 173

A client recruited to participate in a clinical trial to treat non-Hodgkin’s lymphoma tells a nurse and physician that he’s willing to start the trial, but doesn’t know if adverse effects of the treatment will prevent him from completing it. To protect the ethical principle of autonomy, the nurse must tell the client:

Answer 173

that he may withdraw at any time.

Question 174

A client with borderline personality disorder becomes angry when he is told that his psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse is most helpful in dealing with the client’s anger?

Answer 174

You had to wait. Can we talk about how this is making you feel right now?

Question 175

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that:

Answer 175

it may be necessary to raise the head of this client’s bed.

Question 176

The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.

Answer 176

• Vitamin B6.
• Vitamin B12.
• Folate.

Question 177

A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement?

Answer 177

Decreased hematuria

Question 178

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 178

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

Question 179

Which of the following clients would be most appropriate for the nurse to assign to the nursing assistant for morning care?

Answer 179

An elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea.

Question 180

When obtaining the nursing history of a client who has diabetes mellitus, the nurse should assess the client for which of the following early symptom of renal insufficiency?

Answer 180

Polyuria.

Question 181

An 18 month old with a congenital heart defect is to receive digoxin (Lanoxin) twice a day. The nurse should instruct the parents about which of the following?

Answer 181

Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.

Question 182

A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:

Answer 182

isolate the client’s bed linens until the client is no longer infectious.

Question 183

An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician orders a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client’s well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for:

Answer 183

a history of diabetes mellitus.

Question 184

A 4 year old with a history of urinary reflux returned from surgery for bilateral ureteral re-implants 2 days ago. Which assessment finding is most concerning?

Answer 184

Decreased oral intake.

Question 185

A multigravid client at 34 weeks’ gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100° F (37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the primary health care provider to order?

Answer 185

Intravenous penicillin (Penicil).

Question 186

An 18-year-old client is seen in the emergency department following a fall from a horse. After vigorously cleaning a large, dirty laceration on his leg, a nurse closes and dresses the wound. The client has, in the past, received the full tetanus-toxoid immunization regimen, but tells the nurse he had his last shot when he was 11 years old. The nurse should:

Answer 186

plan on administering a dose of tetanus vaccine.

Question 187

The nurse understands that the client who has epidural pain management postoperatively can ambulate because:

Answer 187

A low concentration of analgesia is used with the catheter.

Question 188

Which of the following are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply.

Answer 188

• Medical record number.
• Name band.

Question 189

Which of the following is a late symptom of polycythemia vera?

Answer 189

Pruritus.

Question 190

A pregnant client is experiencing a thin, odorless, vaginal discharge. What should a nurse tell her to do to prevent vaginal infections?

Answer 190

Try wearing a panty liner and discarding it after every urination.

Question 191

A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site?

Answer 191

Change the needle every 3 days.

Question 192

A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which of the following should the nurse expect the primary health care provider to order?

Answer 192

Fresh-frozen platelets.

Question 193

A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

Answer 193

11 weeks’ gestation

Question 194

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Answer 194

Serum potassium level of 3 mEq/L

Question 195

Which action should the nurse take first when admitting an 11-year-old child in sickle cell crisis?

Answer 195

Begin I.V. fluids after obtaining the child’s history.

Question 196

A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to:

Answer 196

walk from his room to the end of the hall and back before discharge.

Question 197

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?

Answer 197

Administering famotidine (Pepcid) as ordered.

Question 198

The nurse is assessing an 80-year-old client who has scald burns on both hands and forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first?

Answer 198

Refer the client to a burn center.

Question 199

A nurse is teaching a client how to administer oxytocin (Syntocinon) for lactation stimulation. The teaching has been successful if the client administers the drug:

Answer 199

sitting with her head vertical.

Question 200

A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse’s best response?

Answer 200

Can you tell me why you want to take your child home now?