ATI (0001-0348)

Question 1

A client newly diagnosed with type 2 diabetes mellitus has returned for a 6-week follow-up visit. The nurse should know that which of the following behaviors indicates that the client has adapted successfully to a situational role change?

Answer 1

Monitors blood glucose once a day

Question 2

After a client views a video on an operative procedure, the best practice for the nurse is to

Answer 2

give the client a handout outlining information relayed in the video.

Question 3

Which of the following nursing actions best promotes client safety when transcribing providers’ orders?

Answer 3

Verify the order sheet contains the correct client indentification

Question 4

A nurse is caring for a client who has a nursing diagnosis of impaired swallowing following a cerebrovascular accident (stroke). Which of the following nursing interventions is appropriate for this client?

Answer 4

Restrict fluid intake.

Question 5

A nurse is caring for a client who gave birth 10 hr earlier. The client is in the takingin phase of psychosocial and maternal adaptation. Which of the following is the most appropriate nursing intervention at this time?

Answer 5

Listen to the mother’s verbalization of her pregnancy and birth experience.

Question 6

A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client?

Answer 6

Laryngeal stridor

Question 7

A nurse is assessing a client who has a nasogastric feeding tube in place. Which of the following actions should the nurse take to prevent aspiration?

Answer 7

Keep the head of the client’s bed elevated at least 30° at all times.

Question 8

A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching?

Answer 8

I will determine which muscles to contract by stopping and starting my stream of unrine

Question 9

A nurse is caring for a client with a terminal illness. The nurse recognizes that the family’s priority need for support will most likely occur when

Answer 9

making decisions about measures to prolong life and provide comfort.

Question 10

A nurse is developing a discharge plan of care for an older adult client on a rehabilitation unit following a cerebrovascular accident. Which of the following has the highest priority when planning care to facilitate a timely discharge?

Answer 10

Arranging for transportation

Question 11

A client with HIV is admitted to the medical-surgical unit with a respiratory infection. The client’s family member requests that fresh flowers be placed in the room every day. Which of the following is the appropriate nursing action?

Answer 11

Teach the family that fresh plants of any type are prohibited.

Question 12

Which of the following is the highest priority for the circulating nurse in maintaining a safe operating room environment?

Answer 12

Reviewing the preoperative assessment

Question 13

A client with a tracheostomy is being sent home to be cared for by the spouse. The nurse should include which of the following information in discharge teaching?

Answer 13

How to properly operate the portable suction machine

Question 14

During the first 24 hr following a soft-tissue injury to the right ankle, which of the following nursing interventions will help reduce the client’s discomfort?

Answer 14

Apply an ice pack to the ankle for 20 to 30 min at a time.

Question 15

A nurse is caring for a client with a mental health disorder. The client is agitated, and the nurse is concerned that the client may become aggressive. Fearful for his own safety, the nurse escorts the client to a room and locks her inside against her will. This action

Answer 15

could result in charges of false imprisonment for the nurse.

Question 16

When instructing a client with an L1-2 spinal cord injury regarding self-care adaptations, which of the following is an appropriate recommendation?

Answer 16

Adaptive devices are available to help you put on your shoes.

Question 17

A 1-year-old child is prescribed ibuprofen after having a febrile seizure. The nurse should teach the parents that the best way to administer the medication is

Answer 17

a suppository.

Question 18

Which of the following strategies best ensures that all nurses on staff have certain skills and knowledge?

Answer 18

Completing annual competence assessments

Question 19

Which of the following manifestations should a nurse expect to find in a client whose blood glucose is 650 mg/dL?

Answer 19

Cool, clammy skin

Question 20

A nurse is caring for a client diagnosed with depression who has been prescribed a tricyclic antidepressant. The nurse should recognize that which of the following client statements indicates an adverse effect that should be reported to the primary care provider?

Answer 20

I haven’t been able to urinate for several hours.

Question 21

A client is scheduled for laparoscopic surgery at 1400. At 1100, the surgeon visits the client’s room and exits after 5 min with a signed informed consent form. The client reports to the nurse that he did not understand the surgeon’s explanation. Which of the following actions should the nurse take?

Answer 21

Explain the procedure to the client and complete documentation.

Question 22

Upon admittance to the hospital, a client states she does not have a written advance directive. After completing the admission assessment, the nurse explains that the client should complete an advance directive because it

Answer 22

finalizes the client’s decisions regarding life-saving measures.

Question 23

A nurse is providing care to a client with a head injury and suspected diabetes insipidus. Which of the following laboratory values should the nurse expect with a diagnosis of diabetes insipidus?

Answer 23

Urine specific gravity of 1.001

Question 24

A nurse is caring for a client who is postoperative for a thyroidectomy. The client is reporting paresthesias and muscle spasms. The nurse should anticipate a prescription for which of the following medications?

Answer 24

Calcium chloride (Calciject)

Question 25

A nurse is caring for a child who has just been admitted to the acute care medical unit. Which of the following laboratory findings should the nurse recognize as indicative of rheumatic fever?

Answer 25

Elevated creatine kinase and troponin

Question 26

A nurse who is a first responder to a biological or chemical attack recognizes that decontamination should preferably be done

Answer 26

near the scene of exposure.

Question 27

Anurse recognizes which of the following older adult clients as being at the highest risk for a fall injury?

Answer 27

A client with aphasia following a cerebrovascular accident

Question 28

A hospital visitor is experiencing a tonic-clonic seizure while visiting a client. To prevent injury to the visitor, the nurse should

Answer 28

clear furniture from around the visitor.

Question 29

A client has just been diagnosed with gestational diabetes and is prescribed insulin injections. She tells the nurse that she doesn’t want to give herself shots and asks why she can’t take a pill instead. Which of the following nursing responses is appropriate?

Answer 29

Pills used to treat diabetes are more likely to cause hypoglycemia.

Question 30

A nurse is caring for a client who had a transurethral resection of the prostate and is receiving a continuous bladder irrigation. At the conclusion of the shift, the nurse collects the following data:

Oral intake = 5 00 mL

Bladder irrigant infused= 3,000 mL

Foley catheter drainage= 4,000 mL

Which of the following is the client’s urinary output?

Answer 30

4,000 mL

Question 31

Which of the following findings should indicate to a nurse that a client has been effectively treated for Mycobacterium tuberculosis?

Answer 31

Sputum culture negative for acid fast bacilli

Question 32

A client wants to review his medical chart, and he asks the nurse if he can see it. The nurse should tell the client that

Answer 32

his request to view his medical chart must be made in writing.

Question 33

Which of the following is an appropriate nursing intervention to take when caring for a client in a crisis?

Answer 33

Help the client to refocus and find constructive ways to cope.

Question 34

A nurse is caring for a client with thrombophlebitis. Which of the following interventions is appropriate for this client?

Answer 34

Elevate legs with a pillow under the knees.

Question 35

A nurse is caring for four clients who are hospitalized. In which of the following client situations should the nurse intervene by notifying the primary care provider?

Answer 35

A client snores loudly and reports headache when awakening.

Question 36

While assessing a client in labor, the nurse observes the umbilical cord protruding from the client’s vagina. After calling for assistance and requesting that the primary care provider be notified, the nurse should immediately

Answer 36

position the client on her side and insert a sterile gloved hand into the vagina to take pressure off the cord.

Question 37

A nurse is planning discharge teaching for the parents of a child with cystic fibrosis. Which of the following is most important for the nurse to emphasize?

Answer 37

Provide an environment that is free of allergens.

Question 38

A nurse is caring for four clients, each of whom has an assistive device. Which of the following clients needs further instruction?

Answer 38

A client who locks both of his elbows when using his crutches to ambulate to the bathroom

Question 39

When performing a mental status examination, a nurse should recognize that which of the following client findings indicates impaired cognition?

Answer 39

The client frequently asks, “Where am I?”

Question 40

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take next?

Answer 40

Reevaluate the client for an ET cuff leak.

Question 41

A client is receiving epoetin alfa (Epogen) for treatment of anemia secondary to bone cancer. Which of the following client findings indicates the hematopoietic growth factor treatment has been effective?

Answer 41

Hemoglobin levels are within normal limits.

Question 42

While visiting a family health clinic, a 19-year-old client requests information regarding the correct use of condoms. Which of the following statements made by the nurse is correct?

Answer 42

When using implanted contraceptive methods, condoms should also be used to protect against STDs.

Question 43

A nurse is caring for a client with an upper gastrointestinal bleed. When performing a saline lavage through a nasogastric tube, the nurse should use which of the following techniques to prevent gastric aspiration?

Answer 43

Instill a minimum volume of 300 mL ofNS.

Question 44

One of the clients assigned to a nurse has become medically unstable. Due to the time the nurse must now spend with this client, provision of care to other assigned clients will be difficult. Which of the following tasks could be delegated to assistive personnel (AP)?

Answer 44

Feeding a client who has a history of aspiration

Question 45

A nurse is providing palliative care to a client and his family. Which of the following statements by the family indicates an understanding of palliative care?

Answer 45

The nurse will help control my father’s pain.

Question 46

When providing safe care to a client being placed in restraints, which of the following nursing interventions is appropriate?

Answer 46

Insert two fingers between the client and the restraint after it is secured to ensure that the fit is loose enough.

Question 47

Staff nurses on a medical unit implement a new program to improve cost effectiveness. Prior to exiting clients’ rooms, the nurses are to ask, “Is there anything I can get you before I leave?” Which of the following suggests that the new program is effective at reducing costs?

Answer 47

The staff nurses are spending less time at the bedside performing non-nursing tasks.

Question 48

A nurse is caring for a child with a new onset of seizures who is about to undergo an electroencephalogram (EEG). Which of the following should be included in teaching the child and parents about the procedure?

Answer 48

Wash the child’s hair with mild shampoo prior to the procedure.

Question 49

A nurse is caring for four clients who are scheduled for surgery today. Which of the following indicates that a client needs further intervention before surgery?

Answer 49

A client whose INR is 2.1 and PTT is 2 times the normal value

Question 50

A nurse is caring for a client with a peripherally inserted central catheter (PICC). Prior to initiating an infusion through the PICC line, the nurse should take which of the following actions?

Answer 50

Confirm placement via chest x-ray.

Question 51

A client is taking an opioid for pain postoperatively. He tells the nurse, “I haven’t had a bowel movement for 3 days, and I normally go every day.” Which of the following is the nurse’s most appropriate response?

Answer 51

A side effect of your pain medication is constipation. I will contact the doctor for a laxative prescription.

Question 52

A nurse is performing initial rounds and assesses four clients. Which of the following occurrences should be documented and reported to the charge nurse immediately?

Answer 52

A client with diabetes mellitus has a blood glucose level of 150 mg/dL.

Question 53

A nurse is directing the care of multiple clients. In determining how to best utilize the skills of a team that includes RN s, licensed practical nurses, and assistive personnel, which of the following is the most important information source?

Answer 53

Team member job descriptions

Question 54

A nurse is caring for a client who has a urinary tract infection and has been receiving a broad-spectrum cephalosporin. Which of the following serum laboratory results indicates medication effectiveness?

Answer 54

WBC 9,200/mm³

Question 55

A nurse is caring for an infant receiving oxygen via an oxygen hood. Which of the following client findings indicates that the client may be experiencing oxygen toxicity?

Answer 55

Substernal retractions

Question 56

A nurse is providing discharge instructions to the parents of a newborn. Which of the following instructions regarding newborn safety is most important for the parents to understand?

Answer 56

Secure the newborn in a rear-facing approved infant car seat when riding in a motor vehicle.

Question 57

A nurse is caring for a client on his first day after having knee surgery. Morning assessment reveals a pain level of 8/10 and a blood pressure of 180/90 mm Hg. Which of the following nursing actions should the nurse take first?

Answer 57

Administer pain medication.

Question 58

A nurse should give priority to which of the following interventions when initiating IV antimicrobial therapy?

Answer 58

Review the client’s allergy history.

Question 59

A child is 6 hr post abdominal surgery. One hour ago, the nurse administered morphine sulfate for pain. Which of the following behaviors is the best indicator that the pain medication has been effective?

Answer 59

Points at smiling face on rating scale

Question 60

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, the nurse should

Answer 60

assist the client into the lithotomy position.

Question 61

Which of the following interventions should the nurse include in the client’s plan of care to prevent development of phlebitis from a peripheral IV?

Answer 61

Flush the IV site every 4 hr.

Question 62

A client’s orders include D5W 1,000 mL over 8 hr. The tubing drip rate is 10 gtt/mL. The nurse should adjust the flow rate to which of the following infusion rates?

Answer 62

21 gtt/min

Question 63

A client is to receive 300 mg phenytoin (Dilantin) by mouth twice daily. The medication is available in a 125 mg/5 mL solution. How many milliliters should the nurse administer for each dose?

Answer 63

12 mL

Question 64

A client with gestational hypertension is experiencing toxic effects from magnesium sulfate therapy. The nurse should anticipate administering which of the following medications to counteract the adverse effects?

Answer 64

Calcium gluconate

Question 65

A newborn whose mother had gestational diabetes is hypoglycemic at birth. Which of the following actions should the nurse take?

Answer 65

Feed the newborn as soon as possible.

Question 66

A nurse in an outpatient clinic is reviewing the results of four clients who have had screening procedures. Which of the following results indicates a need for client follow-up?

Answer 66

Fasting blood glucose level 250 mg/dL; female, age 47

Question 67

A nurse is teaching a client with GERD about omeprazole (Prilosec ). Which of the following indicates a need for further teaching?

Answer 67

I should take it before breakfast.

Question 68

Which of the following statements made by a client indicates that the client has developed trust with the nurse?

Answer 68

I would like to discuss a painful experience.

Question 69

After giving 5 mg of morphine to a client from a 10 mg vial, the nurse should do which of the following with the remaining morphine?

Answer 69

Dispose of it with a licensed witness.

Question 70

A nurse is caring for a client with bone cancer who is taking morphine sulfate to control generalized pain. The primary care provider also prescribes amitriptyline (Elavil). The nurse recognizes that the rationale for the addition of amitriptyline is to

Answer 70

decrease agitation.

Question 71

A 2-month-old infant has received immunizations at a well-child appointment. The nurse should instruct the parent to report which of the following within the first 48 hr?

Answer 71

A fever greater than 38.9° C (102° F)

Question 72

An older adult client who resides in a long-term care facility reports insomnia and excessive daytime sleepiness. To promote rest for the client, the nurse should plan to perform which of the following interventions?

Answer 72

Assess the client’s usual bedtime routine.

Question 73

A client’s advance directive states that he does not want dialysis when his health condition worsens. The client is currently competent and agrees to dialysis. The nurse should

Answer 73

schedule the dialysis since the client is able to make his own decisions.

Question 74

Which of the following best indicates to a nurse that a terminally ill client’s spiritual needs are being met?

Answer 74

The client is able to discuss his thoughts concerning death with the nurse.

Question 75

A nurse should recognize that which of the following older adults is at the highest risk for social isolation?

Answer 75

client who is oxygen dependent and lives alone in an apartment community

Question 76

When performing a 12-lead ECG for a client, the nurse should take which of the following actions?

Answer 76

Place the client in Fowler’s position with arms resting comfortably at his sides.

Question 77

A nurse is discharging a client who has a colostomy. The client states that she would like to use her moisturizing soap to clean around the stoma. Which of the following responses by the nurse is most appropriate?

Answer 77

Lubricants in moisturizing soaps may interfere with adhesion of the appliance.

Question 78

A nurse is providing dietary instruction to a client diagnosed with acute cholecystitis. The nurse recommends which of the following as the most appropriate food choice for lunch?

Answer 78

Fresh broccoli and cauliflower

Question 79

A nurse is caring for a client admitted with a spinal cord injury. After the nurse immobilizes the spine, which of the following is the next priority?

Answer 79

Assess respiratory pattern and effort.

Question 80

Following a gastric resection, a client experiences a cramping sensation, increased pulse rate, dizziness, and nausea after eating a meal. To help reduce these symptoms, the nurse instructs the client to

Answer 80

restrict liquids during, at least 1 hr prior to, and after meals.

Question 81

A nurse is performing a nonstress test on a client who is pregnant at 41-weeks gestation. The nurse notes that the client is having contractions every 2 to 3 min. Which of the following actions should the nurse take first?

Answer 81

Place the client in a side-lying position.

Question 82

A nurse is caring for an older adult client who has chronic renal failure and is prescribed acetaminophen for fever. The nurse can expect that the dosage will be

Answer 82

less than the recommended dose.

Question 83

A nurse is caring for a client immediately following surgery under general anesthesia. The client’s pain is being managed by morphine via a patient-controlled analgesia pump. The nurse should give priority to assessing the client for which of the following adverse medication interactions?

Answer 83

Decreased respiratory rate

Question 84

A nurse is preparing an adolescent client for allergy skin testing. The nurse should expect the adolescent to select which of the following instructional approaches?

Answer 84

Individual instruction by a nurse regarding skin testing in a quiet learning environment

Question 85

A nurse is caring for a client with herpes zoster. Which of the following statements indicates that the client needs more teaching?

Answer 85

I will take ibuprofen for my pain.

Question 86

A client is transferred from the PACU to a private room on the surgical unit. During the nurse’s initial assessment, the client begins to vomit. Which of the following is the nurse’s priority intervention?

Answer 86

Position the client on her side.

Question 87

A primary care provider is about to discontinue a client’s chest tube without giving the client’s preprocedure pain medication time to be effective. Which of the following actions should the nurse take at this time?

Answer 87

Inform the provider that not enough time has passed for the medication to work effectively.

Question 88

A 4-year-old child is being seen in the emergency department after being involved in a motor vehicle crash. The child has a fractured humerus and will be placed in a synthetic cast prior to discharge. Which of the following is an appropriate intervention to include in parent teaching?

Answer 88

Check movement and sensation of the extremity frequently.

Question 89

Parents of an infant ask for information regarding immunization schedules. The nurse should suggest that the parents obtain the most current immunization schedule from which of the following sources?

Answer 89

Centers for Disease Control Web site

Question 90

A nurse is caring for a client who has permanent drooping on the left side of the face following a cerebrovascular accident (stroke). The client refuses to see any family members. Which of the following interventions will best help the client adapt to this body image change?

Answer 90

Educate the client about short- and long-term effects of stroke.

Question 91

A nurse is taking the blood pressure of a client who has come to the clinic for a blood pressure check due to suspected hypertension. Which of the following techniques is appropriate?

Answer 91

Position the client’s arm above the level of the heart while obtaining the reading.

Question 92

A nurse is caring for a client following a total hip arthroplasty. The client’s legs are too large for antiembolic stockings/devices. Which of the following interventions should the nurse expect to implement?

Answer 92

Elevate the foot of the bed.

Question 93

A nurse should recognize that which of the following clients is at greatest risk for developing acute poststreptococcal glomerulonephritis?

Answer 93

A 7-year-old boy recovering from impetigo

Question 94

A nurse is caring for a client with an epidural catheter for opioid administration for pain control. When the nurse is changing the dressing, which of the following is the highest priority?

Answer 94

Preventing catheter dislodgment

Question 95

Which of the following client findings indicates a need for complementary therapy?

Answer 95

A client with diabetes mellitus is noncompliant with his diet.

Question 96

Which of the following findings best indicates that outcomes have been met for a client who has been physically abused by her spouse?

Answer 96

The client reports that she has a safety plan in place and will implement it when necessary.

Question 97

An RN has delegated a Foley catheter insertion to a licensed practical nurse (LPN) for a client who has been unable to void for 10 hr. Which of the following outcomes will require further intervention by the RN?

Answer 97

The LPN reports 60 mL of clear, straw-colored urine output.

Question 98

A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about the disorder. To prevent a sickle cell crisis, the nurse emphasizes the importance of

Answer 98

adequate hydration.

Question 99

A client who is receiving phenytoin (Dilantin) for seizure disorder has been prescribed isoniazid (INH) and rifampin (Rifadin). Which of the following should the nurse conclude if the client develops ataxia and incoordination?

Answer 99

The client is showing evidence of phenytoin toxicity.

Question 100

A nurse is caring for a client who has undergone a modified radical mastectomy. The client has two Jackson-Pratt drains. The nurse should

Answer 100

empty and compress the reservoir.

Question 101

A client who has a second-degree bum tells the nurse that the dressing changes are very painful. Which of the following nursing interventions is appropriate?

Answer 101

Teach the client relaxation techniques to be used during dressing changes.

Question 102

A nurse is preparing an older adult client for discharge. As the nurse is going over the discharge instructions, the client says, “Can I stay at the hospital for a couple more days? My daughter is supposed to stay with me, and I’m worried because we don’t always get along.” The appropriate action by the nurse is to

Answer 102

report a possible case of older adult abuse to the state authorities.

Question 103

When providing nursing care and support for a client with a gambling dependency, which ofthe following is the·most appropriate intervention?

Answer 103

Establish client goals and have the client explain what actions he will take to prevent and manage gambling relapses.

Question 104

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of abuse?

Answer 104

Notify the appropriate state agency about the client’s condition.

Question 105

A nurse is receiving a change-of-shift report on four clients. Which of the following clients is at the greatest risk for developing an infection?

Answer 105

A client who takes prednisone every morning

Question 106

A nurse delegates the task of ambulating a client to an assistive personnel (AP). At the end of the shift, the nurse discovers that the client has not been ambulated. This situation could have best been avoided if the nurse had

Answer 106

emphasized to the AP the importance of ambulating the client.

Question 107

A nurse is planning health promotion education for adolescents. Which of the following interventions is appropriate?

Answer 107

Distribute detailed visual handouts regarding the impact of smoking on lifelong health.

Question 108

A nurse is discussing circumcision with a new mother. Which of the following actions should the nurse take to ensure informed consent?

Answer 108

Explain the consent form for the procedure.

Question 109

A client is diagnosed with an acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin in the emergency department. Which of the following findings indicates that the client is experiencing a satisfactory response to these interventions?

Answer 109

The client’s aPTT is two times the control.

Question 110

A nurse is caring for a client with hyponatremia and heart failure. The assessment reveals moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following should be the nurse’s priority intervention?

Answer 110

Administer diuretics.

Question 111

A nurse is assessing a client who has been taking an estrogen-progestin oral contraceptive. Which of the following side effects should the nurse recognize as being related to an excess of estrogen?

Answer 111

Weight gain

Question 112

A nurse is teaching a client stress management techniques. Which of the following client statements indicates effective learning?

Answer 112

I write in my journal to express my feelings, even though my grammar is bad.

Question 113

A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique?

Answer 113

Balancing the bottle on the sterile basin while pouring the liquid

Question 114

A nurse is providing teaching to a family of an infant with decreased cardiac output due to congenital heart disease. Which of the following strategies regarding care for this infant should be included in the teaching?

Answer 114

Observe for signs of hunger, such as sucking on fists, in order to feed the infant before crying occurs.

Question 115

A nurse is providing discharge teaching to a client following a total hip replacement. Which of the following statements made by the client indicates an understanding of the discharge teaching?

Answer 115

I won’t cross my legs when I sit in a chair.

Question 116

A nurse is providing client teaching regarding sumatriptan (Imitrex). Which of the following client statements indicates that the client understands the expected effects and appropriate uses of this medication?

Answer 116

I should use this medication daily to prevent reoccurrence of my migraines.

Question 117

A nurse is instructing an adolescent recently diagnosed with type 1 diabetes mellitus about self-blood glucose monitoring (SBGM). Which of the following is the most important reason the adolescent should perform SBGM?

Answer 117

Modification of insulin regimen to maintain normal glucose levels

Question 118

A nurse is assigned to care for a client who is managing his own continuous ambulatory peritoneal dialysis treatment at home. The nurse is unfamiliar with the client’s plan of care. The nurse should

Answer 118

review the procedure and care standard.

Question 119

Which of the following assessment findings indicates a complication following an angiogram with a femoral approach?

Answer 119

A decrease in pedal pulse from baseline

Question 120

Which of the following clients is appropriate for the nurse to refer to speech therapy for a swallow evaluation?

Answer 120

An older adult who has difficulty taking in fluids

Question 121

Which of the following is an activity a nurse should engage in to assist in disaster preparedness?

Answer 121

Participate in community drills and mock events.

Question 122

A nurse is caring for a client who has right-sided weakness after a recent cerebrovascular accident (stroke). The nurse should

Answer 122

provide neurosensory stimulation for the client.

Question 123

Following a cerebrovascular accident (stroke), a client experiences right hemiparesis and expressive aphasia. Which of the following best promotes communication among health care team members?

Answer 123

Swallowing precautions are posted above the head of the client’s bed.

Question 124

Which of the following clients should a nurse evacuate first when a fire occurs?

Answer 124

A client who is bedridden and hearing impaired

Question 125

Which of the following nursing interventions should a nurse implement when using music therapy to assist a client in controlling his pain?

Answer 125

Plan for sessions that last about 30 min to maximize the therapeutic value.

Question 126

A client is diagnosed with a pulmonary embolism. Which of the following client findings is consistent with effective treatment?

Answer 126

The client reports feeling less anxious.

Question 127

A nurse is developing a plan of care for an older adult client with hearing loss. Which of the following interventions should be included in the plan?

Answer 127

Get the client’s attention before speaking.

Question 128

A nurse is providing teaching to clients in an outpatient mental health setting. Which of the following client statements indicates understanding of the teaching?

Answer 128

A client taking sertraline (Zoloft) states she knows she will not feel the full benefits for 2 to 3 months.

Question 129

A nurse is caring for a client who is undergoing external radiation treatment for cancer. Which of the following should be included in the client teaching?

Answer 129

Wear protective clothing when out in the sun.

Question 130

A client is admitted with second-degree bums over 30% of her body. She is prescribed 4,080 mL/24 hr of lactated Ringer’s solution IV. Which of the following infusion rates will assure that the client will receive ½ of the total volume within the first 8 hr?

Answer 130

255 mL/hr

Question 131

A charge nurse is attempting to resolve a conflict between two nurses who both insist that the charge nurse favors the other when making daily assignments. Which of the following is the most effective conflict-resolution strategy that the charge nurse can use?

Answer 131

Collaborate with the two nurses when making assignments.

Question 132

A nurse is caring for a client with pneumonia who has just been diagnosed with HIV. The nurse learns that the client’s partner seldom visits since the diagnosis. Which of the following strategies is appropriate for the nurse to implement?

Answer 132

Refer the matter to a social worker.

Question 133

A nurse is caring for a client with Crohn’s disease. Which of the following breakfast menu items is appropriate for this client?

Answer 133

Whole grain cereal

Question 134

A nurse is caring for an older adult client in a long-term care facility. Recent laboratory values show increased hemoglobin, hematocrit, and urine osmolarity. These findings suggest

Answer 134

dehydration.

Question 135

A client is admitted to the emergency department following a motor vehicle crash. Which of the following findings is consistent with hypovolemic shock?

Answer 135

Change in level of consciousness

Question 136

A labor nurse is caring for a woman in active labor who does not speak English. The client grimaces with each contraction but remains silent. The nurse should first

Answer 136

assess the client’s pain level with a visual analog scale.

Question 137

When performing triage during a community disaster, a nurse should understand that the highest priority clients in a disaster situation are those who have lifethreatening injuries and

Answer 137

have a high probability of survival after stabilization.

Question 138

A nurse is caring for a client with heart failure who is receiving D5NS at a rate of 125 mL/hr. The client reports shortness of breath. Which of the following actions should the nurse take first?

Answer 138

Decrease the IV fluid flow rate.

Question 139

When reviewing the ABGs of a client who has uncompensated respiratory alkalosis, the nurse should expect to see which of the following results?

Answer 139

pH of 7.46

Question 140

A nurse is performing a dressing change on a client with an open wound. Which of the following actions should the nurse take to dispose of the soiled dressing?

Answer 140

Put the dressing in a biohazard bag and tie the bag securely.

Question 141

A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse assess first?

Answer 141

A client receiving oxygen via a nonrebreather mask with an SaO2 of 88%

Question 142

A charge nurse must instruct two staff nurses in the use of a new infusion pump. He knows from previous experience that these two nurses are kinesthetic learners. Which of the following teaching methods should the charge nurse use?

Answer 142

Ask the nurses to perform a return demonstration of pump setup and use.

Question 143

A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

Answer 143

PaCO2 level of 55 mm Hg

Question 144

A nurse should recognize and document which of the following as an expected finding for a client with a central vascular access device?

Answer 144

The catheter tip is in the lower third of the superior vena cava per x-ray.

Question 145

A nurse is observing a new graduate, who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the graduate nurse indicates a need for the nurse to intervene?

Answer 145

Uses the TPN IV tubing to administer the client’s next dose of antibiotics

Question 146

A nurse is teaching a client about surgical wound care at home. Which of the following statements by the client indicates an understanding of wound care?

Answer 146

I will call my doctor if I notice drainage from the wound.

Question 147

Which of the following nursing actions is most likely to promote independent dressing in a client who has Stage 1 Alzheimer’s disease?

Answer 147

Give instructions to the client and then leave the room.

Question 148

Which of the following assessment findings indicates that a client is experiencing a complication from conscious sedation?

Answer 148

A client undergoing a bronchoscopy experiences hypoxemia.

Question 149

A client develops anxiety and tachypnea at the start of a blood transfusion. The nurse should take which of the following actions next?

Answer 149

Stop the blood transfusion.

Question 150

A client meets with the nurse for her first prenatal visit. The client’s last menstrual period began on April12. Using Nagele’s rule, the nurse determines that the client’s expected delivery date is

Answer 150

January 5.

Question 151

A nurse refuses to care for a client who frequently comes to the emergency department requesting pain medication. Which of the following actions should the charge nurse take?

Answer 151

Discuss the nurse’s feelings related to this client.

Question 152

A home health nurse is performing an initial assessment of a client’s home. Which of the following must be immediately removed by the nurse?

Answer 152

Frayed extension cords

Question 153

Which of the following client findings is an indication that a client with bipolar disorder is about to experience a relapse?

Answer 153

Is restless and has changes in sleep pattern

Question 154

A client presents to the birthing unit reporting the onset of contractions. Which of the following client findings is consistent with false labor?

Answer 154

Intermittent, painless contractions

Question 155

A nurse is caring for four clients who are using various assistive devices. Which of the following client findings suggests a need for further education regarding appropriate use of an assistive device?

Answer 155

A client asks his wife to place his dentures under his pillow after cleaning them.

Question 156

A nurse is caring for a client admitted to the emergency department following a motor vehicle crash. The Glasgow coma scale rating is 15. The nurse should recognize that the client

Answer 156

is oriented times three.

Question 157

A client is brought to the emergency department with a full-thickness bum of the thorax. Which of the following is the most important nursing intervention?

Answer 157

Initiate IV normal saline.

Question 158

A client has a repair of a retinal detachment. Which of the following interventions should the nurse anticipate implementing to prevent complications during the recovery period?

Answer 158

Administer a stool softener to prevent straining during defecation.

Question 159

A nurse is caring for an infant with gastroenteritis. Which of the following assessment findings should the nurse report to the primary care provider?

Answer 159

The infant has sunken fontanels and dry mucous membranes.

Question 160

A client undergoing surgery is receiving succinylcholine and nitrous oxide. The client’s temperature abruptly rises to 39.4° C (103° F), and the client’s muscles become rigid. The nurse should initially take which of the following actions?

Answer 160

Discontinue administration of the neuromuscular blocking agent.

Question 161

A client is diagnosed with HIV. Which of the following should the nurse plan to teach the client to help prevent the spread of HIV infection?

Answer 161

Use a condom with a petroleum-based lubricant.

Question 162

A nurse can help ensure that a client’s privacy is protected during a pelvic examination by

Answer 162

providing a gown and drape, asking the client to undress from the waist down, and then leaving the room for a few minutes.

Question 163

A nurse is interviewing the husband of a woman who has been admitted in the manic phase of bipolar disorder. The husband states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is most therapeutic?

Answer 163

Could you tell me a little more about what has been happening with your wife at home?’’

Question 164

Which of the following nursing interventions has the highest priority in promoting a therapeutic milieu for a group of clients?

Answer 164

Encourage appropriate social behaviors.

Question 165

A nurse removes an IV catheter from a client who developed phlebitis at a peripheral IV site. Which of the following is the most important piece of data that should be included in the documentation?

Answer 165

Time of day

Question 166

A nurse is assessing a client’s need for restraints. Which of the following is an acceptable reason for the use of physical restraints?

Answer 166

Protecting others from a client’s aggressive behaviors

Question 167

A nurse is caring for four clients who are receiving respiratory medications. The nurse should notify the primary care provider about which of the following client findings?

Answer 167

A client receiving inhaled salmeterol (Serevent) reports a peak expiratory flow in the yellow zone.

Question 168

A client who is a data programmer presents with reports of tingling and numbness of the index and middle fingers of the right hand. Which of the following should be included when teaching about activities to help prevent carpal tunnel syndrome?

Answer 168

Sit with back erect, feet on floor, and shoulders slightly rounded.

Question 169

A client is receiving internal radiation therapy for cervical cancer. Which of the following statements made by the client indicates understanding of the therapy?

Answer 169

When I leave the hospital, I need to avoid the sun.

Question 170

A nurse is caring for a client who is receiving IV potassium chloride for hypokalemia related to the use of potassium-wasting diuretics. The nurse evaluates hypokalemia treatment as successful if which of the following is noted?

Answer 170

Pulse rate becomes regular.

Question 171

A nurse is caring for a client who has a medication order that is unfamiliar to the nurse. Which of the following actions should the nurse take first?

Answer 171

Check a medication reference.

Question 172

To ensure proper client identification when providing care, the best nursing action is to

Answer 172

check clients’ identification bands.

Question 173

A nurse is assessing a client for uterine atony. To assess for atony, the nurse should

Answer 173

palpate the client’s uterus for consistency and placement.

Question 174

A nurse reviews laboratory studies for a client with dyspnea. An elevation in which of the following values indicates that the client’s dyspnea is related to heart failure rather than myocardial infarction?

Answer 174

B-type natriuretic peptide

Question 175

A community health nurse is discussing injury prevention with teachers in a day care. Which of the following developmental factors places toddlers at risk for injury?

Answer 175

Oral fixation

Question 176

Which of the following assessment findings should the nurse expect to find in a 2- year-old child?

Answer 176

Nontender, protruding abdomen

Question 177

A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTis ). Which of the following should the nurse include as a risk factor for developing a UTI?

Answer 177

Using perfumed toilet paper

Question 178

A client has received a transfusion of 250 mL of packed red blood cells. Which of the following findings indicates that the client is responding positively to the transfusion?

Answer 178

The client’s hemoglobin level increases following the transfusion.

Question 179

The roommate of a university student who was recently hospitalized for bacterial meningitis asks if she is in danger of developing the infection. Which of the following is the appropriate response by the nurse?

Answer 179

Bacterial meningitis is spread by contaminated food or water; therefore, infection is unlikely.

Question 180

A nurse is planning care for a client hospitalized with COPD who is experiencing persistent fatigue. Which of the following is an appropriate nursing action to address the client’s fatigue?

Answer 180

Arrange for rest periods between interventions.

Question 181

A nurse is caring for a client who is a rabbi, which of following activities should bP included in plan of care to incorporate religious belief?

Answer 181

Assess client’s nutritional needs and preferences

Question 182

Which of the following laboratory findings indicates the client is at risk for complications following a thorancentesis?

Answer 182

-Albumin 2.1

Question 183

A nurse is caring for a client with nursing diagnosis impaired swallowing following a CVA, which of the following nursing implementation is appropriate for the client?

Answer 183

Place in Fowler’s

Question 184

A nurse is caring for a client who gave birth 10 hours earlier. The client is in the taking in phase of maternal adaptation. Most appropriate intervention at this time?

Answer 184

Listen to mother’s verbalization of pregnancy and birth experience

Question 185

A client is receiving radiation therapy as treatment for breast cancer. Which findings indicates possible development of hypercalcemia as a complication of radiation therapy

Answer 185

gastric distress and renal calculi

Question 186

A client is receiving several different medications during an inpatient stay in a health care facility. Which medications should be suspected when client begins experiencing severe diarrhea?

Answer 186

Celphamine

Question 187

A female client with several stage 4 pressure ulcers is undergoing treatment as prescribed by the wound care consultant. Which findings to the nurse indicates that client’s plan of care needs revision and consultant should be contacted?

Answer 187

loss of 2.3 kilograms(5bs) over past 7 dat

Question 188

A nurse is caring for a client in a long term care setting that provides restorative care which of the following is appropriate when assessing client’s ability to perform ADLs’

Answer 188

monitor client’s ability to perform hygience care

Question 189

A client is admitted with suspected GERD upon receiving the client’s admission laboratory results the nurse notes a troponin level of 0.6ng/DL. Based on this finding the nurse should expect which of the following additions to the client’s pland of care

Answer 189

provide oxygen via nasal cannula

Question 190

A client with HIV admitted to the med surg unit with a respiratory infection, the clien’ts family members requests fresh flowers be placed in the room everyday. Which of following is the appropriate nursing action?

Answer 190

teach that family fresh plants of any type are prohibited

Question 191

During the administration of conscious sedation, a client respiratory rate of 9/min. Client does not respond when asked to lift her right hand, which nursing action is indicated by these findings

Answer 191

actminister oxygen and agents

Question 192

A nurse is caring for a client with AIDS who is antiviral treatment. Which lab values indicate the client is responding to treatment

Answer 192

increased CD4 and lymphocyte count

Question 193

A nurse is caring for 4 clients who have been prescribed various nonpharm interventions, the nurse should intervene first for which of the following clients.

Answer 193

client who is 3 days postop, prescribed icepacks, and rates his pain at 5 out of 10

Question 194

A hospice nurse is making home health visits, which of following findings indicate effective coping

Answer 194

client is communicating funeral preferences to family members

Question 195

A client hospitalized with pnemonia is demonstrating difficulty talking and remaining asleep

Answer 195

environment with reduced noise and light

Question 196

A one year old child is prescribed ibuprofen when having a febrile seizure. Nurse teach parent best way to admin med is

Answer 196

elixir

Question 197

When preparing client for lumbar puncture

Answer 197

lie on your side with knees to your stomach

Question 198

Which of foil manifestations should nurse expect to find whose blood glucose of 650

Answer 198

fruity breath odor

Question 199

Nurse is caring for client with depression, prescribed TCA antidepressant, which of following statements indicated adverse effect that should reported to primary care provider

Answer 199

my eyes have been sensitive to sunlight lately (look it up)

Question 200

A client is scheduled for laproscopy surgery at 1400, At 1100 surgeon visits and after 5 min with informed consent. Client states doesn’t understand surgeons explanations, what should nurse do?

Answer 200

call surgeon and requests he return to client’s room to provide clarification

Question 201

Upon admittance to hospital a client states she does not have a written advance directive. After completing ad miss assess, nurse explains should complete an adv directive because:

Answer 201

guides primary care provider in planning care for individuals in accordance with their wishes

Question 202

A nurse is evaluating effectivess of nonpharm mangt for a client. Which of following findings indicate interventions is effective

Answer 202

client falls asleep after back massage

Question 203

EXHIBIT? A nurse is caring for client post op. Client reports pain level of 10/10 at 8:30, based on the pain assess finding and the client’s information provided the nurse should take which of the following actions next.

Answer 203

call the primary care provider for analgesic intervention

Question 204

A client is admitted to the !CU wj head injury, the ICP is being monitored via an intraventricular catheter, which should nurse include in client’s POC?

Answer 204

avoid overstimulation of the client

Question 205

A nurse who is the first respondent to a biological attack, recognizes that decontamination should preferably be:

Answer 205

near the site of the exposure

Question 206

A nurse should carefully monitor client’s taking Furosemide (Lasix) and which of the following medications:

Answer 206

Gentamycin

Question 207

Nurse is assessing a client who is 36 weeks gestation, which should nurse report to provider?

Answer 207

3+ deep tendon reflexes

Question 208

When developing a client’s trust, the nurse should give priority to which of the following nursing interventions

Answer 208

ensure the confidentiality of the client’s information

Question 209

A nurse is collaborating with other staff nurses to determine staffing needs for a surgical unit, currently the hosp is usihg a client’s identification to determine staffing levels. Which of the following data is most important in planning for optimal staffing?

Answer 209

time of day that most client’s return from the operating room

Question 210

A nurse is caring for a client who is febrile. Reduce fever by giving cooling blanket, which indicates having adverse reaction?

Answer 210

shivering

Question 211

Client wants to review medical chart, ask nurse to see it, nurse tells client:

Answer 211

you have a legal right to review your medical chart

Question 212

Which of foil is appropriate nursing interven to take when caring for client in crisis

Answer 212

Help client refocus and find constructive ways to cope

Question 213

Client is receiving oxytocin (pitocin) to augment labor, which findings indicate to nurse that current dose of oxytocin should be maintained

Answer 213

fetal heart rate increase of 15bts per min with contractions

Question 214

A nurse is dev a discharge care plan for client who has osteoporosis to prevent injury nurse should instruct client to

Answer 214

perform weight bearing excercises

Question 215

while assessing a client in labor the nurse observes that the umbilical chord protruding from the clients vagina after calling for assistance and requesting that the primary care provider be notified the nurse should immediately

Answer 215

position the client on her side and insert a sterile gloved hand into the vagina to take pressure off the chord

Question 216

A nurse is preparing a client for discharge with a? presecribtion for aldactone. The nurse should instruct the client to limit the intake of which of the following foods

Answer 216

banannas and citrus fruits

Question 217

A nurse is to perform a dressing change for a client with a burn wound identify the sequence the nurse should follow. (this one you put in order in the box)

Answer 217

• medicate with analgesic
• remove previous dressing
• assess for edema draininage and discharge
• apply a thin layer topical antibiotic ointment as prescribed
• observe wound as prescribed

Question 218

when performing a mental status examination the nurse should recognize that which of the client finding indicate impaired cognition

Answer 218

the client frequently asks where am I

Question 219

A nurse is working on an orthapedic surgical unit … where slide back chairs are used to assist client to get out of bed and increase mobility. there are not enough chairs to serve all the clients, which of the following actions is important for the nurse to take

Answer 219

Has the need for further equipment to meet client care demands

Question 220

a client if revievieng a epoetin alpha (epogen) for treatment of anemia secondary to bone cancer which of the following client findings indicate hematopoesis growth factor treatment has been effective?

Answer 220

hemoglobin level are with in normal limits

Question 221

while visiting a family health clinic a 19 year old … regarding the correct use of condoms. Which of the following statements made by the nurse is correct

Answer 221

when using implanted contraceptive methods condoms should also be used to protect against STD’s

Question 222

a nurse is assessing a client who is near the end of her first trimester during the routine prenatal exam. When checking to determine whether or not the fetal heart rate can be detected the nurse should

Answer 222

Move the fetal scope along the midline just above the pubis while applying firm pressure

Question 223

A client is admitted with a history of transient ischemic attacks. To prevent injury while hospitalized, the nurse should

Answer 223

complete a fall risk assessment upon admission

Question 224

A nurse is providing pallative care to client and family. Which statement by family indicates understanding ofpallative care

Answer 224

the nurse will help relieve my father pain

Question 225

A nurse is caring for a client with GERD, which of foil assessment findings should nurse expect to find

Answer 225

atypcial chest pain

Question 226

A client is prescribed 500 mg penicillin JM, the 2gm of pen in vial should be diluted with 10m! of normal saline before admin the dose, nurse should check that there are how many ml in syringe

Answer 226

2.5

Question 227

A nurse is caring for a child with a new onset of seizures who is about to undergo an EEG, which of the following should be included in teaching child and parents about the procedure

Answer 227

wash child’s hair with mild shampoo prior to procedure

Question 228

a nurse is caring for 4 clients who are scheduled for surgery today, which a following indicates that a client needs further intervention b4 surgery

Answer 228

client’s INR 2.1, PTT is 2 times the normal value

Question 229

Which of the following assessment following indicate proper use of crutches by a client?

Answer 229

client’s positions hands on grips with elbows slightly flexed

Question 230

A nurse is planning discharge teaching for a client who will continue receiving chemo for treatment of leukemia in the outpatient clinic. Which offoll should nurse include

Answer 230

avoid salads, raw fruits and veggies

Question 231

Which of the fall nursing actions is an example of safe cost effective care

Answer 231

remove unused IV infusion pump from the client’s room

Question 232

An adolescent who is being seen in the outpatient clinic reports she has had a low grade fever, headache, sore throat, swollen lymph nodes for about four days. This morning she developed a pinkish red macular popular rash on her face and neck. Which of the following is an approprate nursing action

Answer 232

isolate her from any pregnant woman

Question 233

A client is being transferred from one health care facility to another. To ensure continuity the nurse who is transferring the client should give priority to inclusion of which of the following information

Answer 233

an assessment of the client’s tolerance of physical activity

Question 234

A client in ESRD has a serum potassium of 6.2mEQ/L. The nurse should anticipate implementing which of folio interventions first?

Answer 234

initiate continuous cardiac monitoring

Question 235

A nurse is providing discharge instructions to the parents of a newborn. Which of following instructions regarding newborn safety is most important for the parents to understand?

Answer 235

secure the newborn in a rear-facing approved infant car seat when riding in a motor vehicle

Question 236

A nurse is caring for a client on his first day after having knee surgery. Morning assessment reveals a pain level of 8/10 and bp of 180/90mmHG. Which of the following nursing actions should nurse take first?

Answer 236

admin pain med

Question 237

A nurse should give priority to which of the foil interventions when initiating IV anitmicrobial therapy

Answer 237

review the clients allergy history

Question 238

A school nurse is performing scolosis screening. Which of fall clinical signs will be evident in a student who has scolosis?

Answer 238

uneven shoulder and pelvic height

Question 239

A nurse is positioning a client for Cesearen birth. To prevent a compromise in placental blood flow during the intraoperative period, the nurse should

Answer 239

place a wedge under one of the client’s hips

Question 240

A nurse is providing care to a client who has Hep A. Nurse should recognize which of following nursing actions poses risk for transmission of the disease

Answer 240

emptying the fecal matter

Question 241

During a well child visit for a toddler. The nurse should include which of the folll when discussing age specific growth and dev?

Answer 241

it is normal for your child to … say whose and …… and pronounce single syllabus words at this age

Question 242

A nurse is evaluating whether an in service for the organiz structure of the unit was effective. The staff have been heard complaining about the charge nurse not being assigned clients. The nurse can accurately deduce from the responses that the

Answer 242

inservice needs to be repeated so staff are more clear on the proposed change

Question 243

A client is to receive a puendedal block while giving birth. The nurse should expect that a puendal block will

Answer 243

diminish pain in the perineum

Question 244

Which of the following statements by a parent of a newborn indicates that discharge teaching regarding care of a circumcision has been effective?

Answer 244

I will give my baby sponge until the circumcison has healed

Question 245

A nurse is providing discharge instructions to the parent of a newborn. The nurse determines parent requires further teaching regarding use of a bulb syringe if she states

Answer 245

I should insert the syringe in the center of his mouth

Question 246

The nurse is teaching a client with GERD about omerprazole (Prilosec). Which of the following indicates a need for further teaching?

Answer 246

it will decrease the pH level in my stomach

Question 247

A nurse is caring for a client wj an indewelling urinary catheter. Which of the foil actions should nurse take to provide appropriate catheter care?

Answer 247

Provide perineal hygiene at least twice a day

Question 248

A nurse is teaching a client who just had a repair of retinal detachment. Which of foil client statement indicates a need for further teaching

Answer 248

I can do quiet activities such as reading or sewing

Question 249

A nurse is caring for a client who is receiving continuous tube feedings via a NG tube. The client appears restless and abdomen is distended. Which offoll actions should nurse take first?

Answer 249

check the residual volume

Question 250

During assessment of a client with pneumonia. The nurse documents the following findings:

Client alert, oriented, restless

BP is 148/65mmHG

Oxygen saturation of 86% (while on 02 at 2L/min per nasal cannula

Heart rate is 94/min

Respirations is 24/min

The client is currently receiving IV at 100ml/hour and morphine sulfate. Which of the following actions should the nurse take next.

Answer 250

increase the oxygen flow rate

Question 251

A nurse is caring for a client with fingerstick blood glucose level of 42mg/DL. Which of the foil findings is consistent with the lab values

Answer 251

anxiety and confusion

Question 252

A nurse notices an unfamiliar staff member entering the obstetrical unit. Which of the following is the most appropriate intervention

Answer 252

stop staff member and verify identification

Question 253

A nurse is caring for a client with Crohns disease receiveing TPN. Which of the foil findings is most indicative that the client is responding positively TPN therapy.

Answer 253

average weight gain of 1Kg/ day

Question 254

A nurse is caring for a client who had a recent spinal cord injury and is quadriplegic. Which of the following assessment finding is a complication related to immobility

Answer 254

crackles in the lower lung fields

Question 255

A client had major abdominal surgery 24 hours ago. Which of the following is the best indication that postop nursing intervention have been effective in preventing resp complications

Answer 255

client is able to breath deeply and to forcefully cough while splinting

Question 256

A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Nurse should recognize which of following indicates an adverse affect that must be reported to the primary care provider

Answer 256

client is observed displaying a shuffling gait while walking in the hall

Question 257

A nurse is planning care for an older adult client with a cognitive disorder such as Alzheimer’s Which of the foil interventions should be included in the client’s plan of care. Select all that apply

Answer 257

• give client one simple direction at a time
• establish eye contact and use touch when communicating with client
• reinforce orientation to time, place, and person.

(unsure about answer)

Question 258

A nurse is caring for a client who has just received the first dose of Lisinopril. Which of the following is appropriate nursing intervention

Answer 258

provide standby assist when client gets out of bed

Question 259

Following a gastric resection, client experiences a cramping sensations, increased pulse rate, dizziness, and nausea, after eating a meal. To help reduce sx nurse instructs client:

Answer 259

restrict liquids during, at least one hour prior to, and after meals

Question 260

A diet reports to an RN that another nurse smells like alcohol Which of the following should the RN take next:

Answer 260

Gather any additional information from the client and then notify the nurse manager

Question 261

A nurse for an older client who has chronic renal failure is prescribes acetaminiphen for fever. The nurse can expect that the dosage will be:

Answer 261

less than recommended does

Question 262

A nurse is admitting a client who is taking prednisone 10 mg daily for 10 mg for 10 months. Which of the following findings indicate a side effect of this medication therapy.

Answer 262

thin extremities with obesity of the stomach

Question 263

A wife is acting as a primary care giver to her spouse with Alzheimer’s disease who is homebound. The home health nurse recognizes signs of ineffective coping and caregiver distress. The nurse should take which of the following actions initially:

Answer 263

Provide information on local support groups for the wife to attend

Question 264

The nurse is caring for a client with herpes zoster. Which of the following statements indicate the clients needs more teachmg?

Answer 264

I will apply astrigent compresses to the lesions three times a day

Question 265

A Child with diabetes mellitus has a blood glucose level of 343mg/DL the nurse anticipates which of following action

Answer 265

Request a bilingual Spanish-speaking female translator through the facility.

Question 266

A nurse is caring for a child with iron deficiency anemia. Which of the following lab values should nurse expect to find?

Answer 266

decreased hematocrit

Question 267

A nurse is receiving the past medical history of a client admitted for agina. Which of the following is a risk factor for angina?

Answer 267

hyperlipidemia

Question 268

Which of following findings best indicate that outcomes have been met for a client who has been physically abused by her spouse?

Answer 268

client reports that she has a safety plan in place and will implement it when necessary

Question 269

Nurse caringfor a client admitted with …. fluid volume excess due to heart failure. Which of foil assessment findings validates client’s hypervolemia has been resolved?

Answer 269

BUN 8mg/DL

Question 270

Nurse is assessing a preschooler who has recently experienced an unexpected death in the family. Which should nurse recognize as an expected finding?

Answer 270

child believes the person will return

Question 271

A client who is receiving Phenytoin (Dilantin) for seizure disorder has been prescribed INH and Rimfapin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

Answer 271

client is showing evidence of phenytoin toxicity

Question 272

A nurse is caring for a client who has undergone a modified radial mastectomy. A client has to jackson Pratt drains. The nurse should

Answer 272

empty and compress the reservoir

Question 273

A client who has a second-degree burn tells the nurse that the drsg changes are very painful. Which of the foil nursing interventions is appropriate?

Answer 273

teach client relaxation techniques to be used during drsg changes

Question 274

Which of the following nursing actions appropriately maintains client confidentiality?

Answer 274

a nurse removes an open chart from the nurse’s station counter and places it on the chart rack .

Question 275

When providing nursing care and support for a client with a gambling dependency. Which of the following is the most appropriate intervention.

Answer 275

Establish clients goals and have the client explain what actions he will take to prevent and manage gambling relapses

Question 276

A client in labor is undergoing a vacuum assistive birth. Which fthe following should the nurse perform at the conclusion of the procedure.

Answer 276

Perinial assessment for trauma (other option missing)

Question 277

A nurse delegates the task of ambulating to a client to an assistive personnel at the end of the shift the nurse discovers that the client has not bee.en ambulated. The situation could have been best avoided if the nurse had:

Answer 277

emphasize to the AP the importance of ambulating the client

Question 278

Which of the following interventions by the nurse to is most appropriate to decrease potential infections for a child with leukemia who is receiving chemotherapy.

Answer 278

Screen and limit the childs visitors

Question 279

A client uses prescribed hydrocodone(vicodin) insisting oxycodone perkasett has resolved pain in the past. Knowing that the prescribed provider prefers hydrodone which of the follwing actions should the nurse take.

Answer 279

inform the prescribing provider of clients preference

Question 280

a·nurse is caring for an infant with gatroentiritis which of the following assessment findings should the nurse report to primary care provider?

Answer 280

infant has decreased appetite and irritable

Question 281

A nurse is caring for a client been discharged on warfarin, which of the following home medication should the nurse question?

Answer 281

asprin 81mg

Question 282

A client is diagnosed with an acute Ml and is being treated with a thrombolytic agent and iv heparin in the emergency department which of the following finding indicates that the client is experiencing a satisfactory response to this intervention

Answer 282

the client aptt is 2 times the normal value

Question 283

A nurse is assessing the fontanells in a 8 month old infant which of the following is an expecxted finding

Answer 283

anterior font. Should be open

Question 284

The nurse is assessing a client brought to the hospital psych services by a law enforcement officer the client has disorganized incoherent speech with … association and religious content client has flat affect, poor hygenen, repeptitive hand gestures the nurse recognizes these signs and symptoms as being most consistant with which of the following

Answer 284

schizophrenia

Question 285

A client who is insulin dependent is .. which determines ifthe clients blood gluclose level is controlled? ·

Answer 285

h a1c of 6.5

Question 286

A nurse is preparing to perform a sterile wound irrigation and dressing change for a client which of the follo:wing actions by the nurse breaks surgical aseptic technique

Answer 286

balancing the bottle on the sterile basin while pouring the liquid

Question 287

A nurse is providng teaching for a family of an infant with decreased cardiac output with congenital heart disease which of the following for providing care should be included in the teaching

Answer 287

observe for signs of hunger such sucking of fist … in order to feed infant before crying occurs.

Question 288

The nurse is providing discharge teaching to a client following a total hip replacement which of the indicates a proper understanding of discharge instructions

Answer 288

I wont cross my legs when I sit in a char

Question 289

A nurse is caring for a client following surgery for open angle glaucoma which of the following should be included in the clients care plan

Answer 289

instruct client to wear a patch over the affected eye

Question 290

A nurse is instructing an adolescent recently diagnosed with type 1 DM about self blood glucose monitoring which of the following reactions that adolescents should adolescents perform ·

Answer 290

coorelation of blood glucose with activity

Question 291

A charge nurse on a cardiac step down unit is receiving a float nurse from a l&D unit which of the following assignments should the charge nurse give to the float nurse

Answer 291

a client who is 3 days post cardiopulmonary artery bypass surgery

Question 292

An older adult client moves in with her daughter and her family. the daughter tells the visiting nurse that there is a great deal of stress in the family because the father is interfering with parental decisions, the nurse should take which of the following actions to help integrate the older adult client into the family structure

Answer 292

facilitate a family meeting to discuss and resolve issues related to changes in the family structure

Question 293

A nurse is caring for a client with esoph. Varicies the client is vomiting bright red blood which of the following actions should be taken to protect the client.

Answer 293

suction the oropharynx

Question 294

Which of the following activites should a nurse engage in to assist in disaster prep redness

Answer 294

participate in community drills and mark … ?

Question 295

A nurse is caring for an adult client with chronic anemia who is to receive a transfusion of 1 unit of packed RBC’s which of the following actions is appropriate

Answer 295

flush the blood transfusion tubing with normal saline prior to the transfusion

Question 296

Following a CVA a client with right hemiparesis and expressive aphasia which of the following best promotes communications among the health care team members

Answer 296

interedisciplinary team meetirig are held on a regular basis

Question 297

A nurse is caring for a client to has undergone alcohol detox to promote alcohol abstinence which of the following should be included in the clients plan of care

Answer 297

promote the development of new coping strategies to prevent relaspses

Question 298

A client has a diminished gag reflex is recieivng 60 % 02 through partial rebreather ask and has received haldol prn for anxiety. The client is trying to climb out of bed with increased respiratory rate and loud rhonchi which of the following actions should the nurse take first

Answer 298

perform nasotracheal suction and monitor clients reponse

Question 299

When reviewing the lab results of a client with primary hypothyroidism the nurse should expect an increase in which

Answer 299

thyroid stimulating hormone TSH

Question 300

A nurse should instruct an assitive perscinelle to provide a verbal report immediately upon acquisition of which of the following client information

Answer 300

finger stick blood gluclose of client receieving sliding scale insulin

Question 301

Which of the following nursing action best promotes safety when using chemotherapeutic agents

Answer 301

wear personal protective equipment when handling agents

Question 302

A client is admitted with second degree burns over 30 percent of her body she is prescribed 4080 ml per 24 hour of lactated ringer solution IV which of the following infusion rates will ensure that the client will receive half of the total the first 8 hours

Answer 302

255 ml per hour

Question 303

a nurse is montitoring a client with a prescription of continusou IV heparin at 1000 units per hour the IV bag from the pharmacy contains 50 units per ml. thorught the shift the nurse should ensure that the IV infusion pump is delivering the heparin at the rate of how many ml per hour

Answer 303

20

Question 304

A nurse is assisting a client with acute glomerular nephritis. To choose menu choices for break fast which of the follwing is a good choice

Answer 304

bagel

Question 305

A nurse is caring for a client with chrons disease which of the following breakfast menu options is appropriate

Answer 305

pouched eggs

Question 306

A nurse is caring for an older adult client in a long term care facility, recentllab values shows increased hemoglobin, hematocrit, and urine irregularity which finidings suggest anemia

Answer 306

dehydration

Question 307

A client is admitted to the ED following a motor vehicle crash which of the following findings is consistailt with hypovolemic shock

Answer 307

change in LOC

Question 308

A nurse is preparing discharge instructions with a post op clients with transverse abdominal incision. Which of the following indicates nurses teaching is effective

Answer 308

the client lists indications to call the primary care provider such as incisional warmth and redness

Question 309

A student nurse has been instructed on proper body mechanics to prevent personal injuries during client lifts and transfers which of the following is correct info for the nurse to include

Answer 309

when a client up in bed tighten abdomen muscles.

Question 310

A nurse is reviewing the chart of 4 clients who have come into a public health clinic based on the life style choices of each of the clients which of the following clients are in need of further assessments

Answer 310

a client who jogs everyday and applies ice to his shins for 20 mins after running

Question 311

A nurse is caring for a child following a tonsillectomy which of the following findings indicates that the client is experiences hemmorage

Answer 311

frequent swallowing

Question 312

A nurse should recognize and document which of the following as an expected finding for a client with a central vascular access device

Answer 312

the catheter tip is in the lower 3rd of superior vena cava per xray

Question 313

A client with pneumonia I feel like an elephant is on my chest the client is weak and unable to walk after the nurse initiates chest pain protocol, which of the following is priority diagnostic test

Answer 313

chest x-ray

Question 314

The nurse is performing an admission history on a client who is being admitted to a mental health unit a. The client has a diagnosis of borderline personality disorder. based on this diagnosis, the nurse should assess the eli net for which of the ffing

Answer 314

a pattern of unstable ………… in which the client alternatively idealizes and devalues others

Question 315

Which of the following nursing action is most likely to promote independent dressing in a client who has stage 1 alzhemiers disease

Answer 315

lay out the appropriate clothing for the client each day

Question 316

The client is receieving gentamyacin pre op of ruptured appendix which of the following assessment finding indicate an adverse effect of medication

Answer 316

creatin 2.3

Question 317

A nurse notes that a client rythym has changed to a fib which of the following finding should be reported immediately

Answer 317

chest pain

Question 318

A client meets with the nurse for a first prenatal visit. The clients last menstrual period began April12 th. Using naegals rule the nurse determines EDD is?

Answer 318

Jan 19

Question 319

Nurse caring for client with new colostomy which of the following interventions is appropriate for preventing skin break down.

Answer 319

cut the opening of the cut-to- fit pouch 1- 1/6 inch larger the stoma

Question 320

A nurse is assessing a client in skeletal traction for a fractured tibia which of the following clinical findings indicates altered tissue perfusion ofthe affected extremity

Answer 320

pedal pulse 1+

Question 321

Which of the following client findings of a client with bipolar disorder is about to relapse

Answer 321

restless and has changes in sleep pattern

Question 322

A nurse has just received change of shift report. Based on the info provided which of the following clients should be assessed first

Answer 322

a client who was jut given a glass of orange juice for low glucose level

Question 323

A nurse is instructing a parent of an infant with a cleft lip/ pal at which of the following feedking techniques is appropriate to include in the teaching

Answer 323

burp frequently during feedings

Question 324

A nurse should recognize that which of the following clients is ready for a rehab referral.

Answer 324

client who is 2 weeks post spinal chord injury.

Question 325

a client is brough to ED with full thickness burn on thorax which of the following is the most important nursing intervention

Answer 325

obtain ABG

Question 326

A client uses prescribed hydrocodone(vicodin) insisting oxycodone perkasett has resolved pain in the past. Knowing that the prescribed provider prefers hydrodone which of the follwing actions should the nurse take.

Answer 326

inform the prescribing provider of clients preference.

Question 327

a nurse is caring for an infant with gatroentiritis which of the following assessment findings should the nurse report to primary care provider?

Answer 327

infant has decreased appetite and irritable

Question 328

Nurse caring for client in preterm labor to receives two doses of bethamethasone 24 hours apart the nurse should tell the client that the purpose of the medication is to decrease the risk of

Answer 328

new born respiratory distress

Question 329

A nurse shoule recognize that which of the following clients needs a referral for PT

Answer 329

a client with left sided weakness due to CVA

Question 330

A nurse can help ensure a clients privacy is protected during pelvic exam by

Answer 330

providing a gown and drape, askingthe client to undress from waste down and leaving the room for a few minutes .

Question 331

A client has been taking glucocortocoid for severe rheumatoid arthritis which of the following client statements indicates a need for further education

Answer 331

I will immediately quit taking the medication if I have Gi distress

Question 332

A home health nurse is assessing the home environment of a client with alzhemiers disease which of the following should be corrected

Answer 332

extension chord placed under rug

Question 333

A nurse is caring for a client in the ICU who is on mech vent when a fire starts in the room after turning off o2 supply which action should nurse take next

Answer 333

ventilate with ambu bag and evacuate the room

Question 334

A 12 year old child is scheduled for tonsillectomy in 2 weeks outpatient scheduling nurse should plan to meet the psuchosocial needs of child by a. explain hospitalization morning of surgery

Answer 334

allowing child to participate dirung informed consent from parents

Question 335

A nurse in the ED is caring for a child who is experiencing an acute asthma attack Child is receving albuteral by nebulizer for which of following adverse effects should nurse monitor

Answer 335

tachycardia

Question 336

A nurse is teaching a client about measures to decrease stress incontinence the client is most likely to benefit from

Answer 336

kegel exercise

Question 337

An orientation program is being developed for new staff which is most beneficial in assisting new staff for work place

Answer 337

paired work with expert staff nurse

Question 338

Nurse is caring for a client who is receiving iv potassium choride for hypok+ related to use k+ wasting diuretics, the nurse evaluates hypokalemia treatment as successful if which of the following is noted

Answer 338

pulse rate becomes regular

Question 339

Nurse caring for client with medication order unfamiliar to the nurse. Which of the foll actions should nurse take first

Answer 339

check a medication reference

Question 340

A client develops a lower left leg DVT following surgery. This development indicates a need for which of the following additions or revisions to client’s plan of care

Answer 340

apply warm moist compress to affected extremity

Question 341

Nurse is assessing client for uterine atony. To assess for atony, the nurse should

Answer 341

palpate the client uterus for consistency and placement

Question 342

A nurse is evaluating teaching effectiveness for client to be discharged on Digoxin. Which client statement indicates need for further instruct

Answer 342

I should expect to experience some nausea while taking medication

Question 343

ln caring for a client with central line catheter a nurse should take which of the foB actions

Answer 343

after removing drsg compare the external catheter length with original length at insertion

Question 344

A nurse is caring for a client who was given 10000 U of IV heparin rather than prescribed 1000 U, the nurse should give priority to which of the foll actions

Answer 344

assess for signs of bleeding

Question 345

Client diagnosed with COPD is being discharged home with oxygen therapy. Upon discharge the nurse provides instructions to the client on how to use the equipment. Which of following statements by client indicates understanding of nursing instructions?

Answer 345

l should use water based ointment around my nostrils if they get dry

Question 346

A charge nurse is making client assignment on a med surg unit for the day. Which of the foil tasks is appropriate for the charge nurse to delegate to a LPN on the unit

Answer 346

programming a PCA infusion pump

Question 347

The roommate of a univ student recently hospitalized for bacterial meningitis ask if she is in danger of developing the infection. Which of the foil is the appropriate response by the nurse

Answer 347

bacterial meningitis can be prevented if antibiotics are taken after exposure to infection

Question 348

A nurse is planning care for a client hospitalized with COPD who experiencing persistent fatigue. Which of following is an appropriate nursing action to address client’s fatigue

Answer 348

arrange for rest periods between interventions