B

Question 1

(NGN)

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client’s chart, which of the following findings should the nurse report to the provider?

(Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

A. Potassium 4.1 mEq/L
B. HR 55/min
C. SaO2 92%
D. Weight 67.1 (148 lb)

Answer 1

Heart rate 55/min

Question 2

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects?

A. Electrically generated feelings of heat
B. Cryotherapy for painful areas
C. Realignment of energy flow through meridians
D. A tingling sensation replacing the pain

Answer 2

D. A tingling sensation replacing the pain

Question 3

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s triad?

A. Hypotension
B. Tachypnea
C. Nuchal rigidity
D. Bradycardia

Answer 3

D. Bradycardia

Question 4

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer’s disease. Which of the following information should the nurse include in the teaching?

A. Position tabletop clocks with multi-colored backgrounds throughout the home.

B. Explain how to complete a task while having the client do the task.

C. Place a calendar on the wall with days and weeks included.

D. Create complete outfits and allow the client to select one each day.

Answer 4

D. Create complete outfits and allow the client to select one each day.

Question 5

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?

A. Encourage the client to eat raw fruits and vegetables.
B. Avoid placing plants or flowers in the client’s room.
C. Limit visitors to members of the client’s immediate family.
D. Wear an N95 respirator mask when providing care to the client.

Answer 5

B. Avoid placing plants or flowers in the client’s room.

Question 6

A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching?

A. Take an antacid before meals and at bedtime.
B. Increase fiber intake to at least 30 g per day.
C. Drink ginger tea daily.
D. Consume no more than 1 L of water per day.

Answer 6

B. Increase fiber intake to at least 30 g per day.

Question 7

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

A. Low urine specific gravity
B. Hypertension
C. Bounding peripheral pulses
D. Hyperglycemia

Answer 7

A. Low urine specific gravity

Question 8

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 8

167

Question 9

(NGN)

A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy.

Click to highlight the findings the nurse should report to the provider immediately.

Answer 9

• Perineal pad saturated with blood, large clots present
• Change of blood pressure, heart rate of 102/min

Question 10

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client’s bedside?

A. Suction machine
B. Wire cutters
C. Padded clamp
D. Communication board

Answer 10

A. Suction machine

Question 11

A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching?

A. “I will avoid eating raw fruits and vegetables.”

B. “I can ask a friend to change my cats litter box.”

C. “I will use a mild soap when washing my genital area.”

D. “I can sip on a glass of juice for at least 2 hours before I should discard it.”

Answer 11

B. “I can ask a friend to change my cats litter box.”

Question 12

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take?

A. Inspect the cast for drainage once every 24 hr.
B. Check that one finger fits between the cast and the leg.
C. Perform neurovascular checks every 2 to 3 hr.
D. Make sure the client has a warm blanket covering the cast

Answer 12

B. Check that one finger fits between the cast and the leg.

Question 13

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?

A. Shellfish
B. Peanuts
C. Eggs
D. Avocados

Answer 13

D. Avocados

Question 14

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

A. 240 mL (8 oz) of orange juice
B. 1 ampule of 50% dextrose IV bolus
C. NPH insulin 60 units subcutaneous
D. Regular insulin 20 units IV bolus

Answer 14

D. Regular insulin 20 units IV bolus

Question 15

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

A. “I will wash the ink markings off the radiation area after each treatment.”
B. “I will use my hands rather than a washcloth to clean the radiation area.”
C. “I will be able to be out in the sun 1 month after my radiation treatments are over.”
D. “I will use a heating pad on my neck if it becomes sore during the radiation therapy.”

Answer 15

B. “I will use my hands rather than a washcloth to clean the radiation area.”

Question 16

A nurse is caring for a client who is experiencing supra-ventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take?

A. Defibrillate the client’s heart.
B. Perform synchronized cardioversion.
C. Begin cardiopulmonary resuscitation.
D. Administer lidocaine IV bolus.

Answer 16

B. Perform synchronized cardioversion.

Question 17

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client’s initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

A. Heart rate 110/min
B. Blood pressure 160/70 mm Hg
C. Respiratory rate 14/min
D. Temperature 38.4° C (101.1° F)

Answer 17

Heart rate 110/min.

Question 18

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions?

A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.

B. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy.

C. Family members should follow airborne precautions at home.

D. A follow-up tuberculosis skin test is necessary in 2 months

Answer 18

A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.

Question 19

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

A.Restlessness
B. T3 level 215 ng/dL (40 to 180 ng/dL)
C. Blood pressure 170/80 mm Hg
D. Decreased weight

Answer 19

C. Blood pressure 170/80 mm Hg

Question 20

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

A. Keep a lead-lined container in the client’s room.
B. Limit each visitor to 1 hr per day.
C. Place a dosimeter badge on the client.
D. Remove soiled linens from the client’s room each day.

Answer 20

A. Keep a lead-lined container in the client’s room.

Question 21

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of-the following supplements can interfere with the effectiveness of the medication?

A. Ginkgo biloba
B. Glucosamine
C. Calcium
D. Vitamin C

Answer 21

C. Calcium

Question 22

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?

A. Change the dressing every 72 hr.
B. Immobilize the hand with a pressure dressing.
C. Take pain medication 30 min after changing the dressing.
D. Wrap fingers with individual dressings.

Answer 22

D. Wrap fingers with individual dressings.

Question 23

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?

A. History of Asthma
B. Appendectomy 1 year ago
C. Penicillin allergy
D. Total knee arthroplasty 6 months ago

Answer 23

A. History of Asthma

Question 24

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

A. Blood sodium level 132 mEq/L (136 to 145 mEq/L)
B. Forearm skin tents when pinched
C. Respiratory rate decreased
D. Urine specific gravity 1.045 (1.005 to 1.03)

Answer 24

D. Urine specific gravity 1.045 (1.005 to 1.03)

Question 25

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? A. Hyperreflexia B. Increased blood pressure C. Respiratory paralysis D. Tachycardia

Answer 25

C. Respiratory paralysis

Question 26

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? A. Remove the client's indwelling urinary catheter. B. Irrigate the indwelling urinary catheter. C. Clamp the indwelling urinary catheter. D. Apply traction to the indwelling urinary catheter.

Answer 26

B. Irrigate the indwelling urinary catheter.

Question 27

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

Answer 27

"I will wear clean graduated compression stockings every day."

Question 28

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? A. Monitor the client's INR daily. B. Expel air bubbles when using a prefilled syringe. C. Inject the medication into the anterolateral abdominal wall. D. Massage the injection site after administration.

Answer 28

C. Inject the medication into the anterolateral abdominal wall.

Question 29

A nurse is caring for an client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? A. Check on the client every 2 hr. B. Provide a quiet environment with no distractions. C. Turn on the television in the client's room. D. Keep the client occupied with a manual activity.

Answer 29

D. Keep the client occupied with a manual activity.

Question 30

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? A. Increased potassium B. Increased magnesium C. Increased BUN D. Increased hematocrit

Answer 30

C. Increased BUN

Question 31

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulder C. Rebound abdominal tenderness D. Tachycardia

Answer 31

D. Tachycardia

Question 32

(NGN) The nurse is providing care for the client. The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Answer 32

12 % weight loss over 2 months Muscle guarding and tenderness in right lower quadrant of abdomen Abdominal firmness and rigidity Abdominal pain rate of 8 Hypoactive bowel sounds Report of anorexia Temperature of 38.5 C (101.4 F)

Question 33

(NGN) A nurse is caring for a client. The nurse has completed their performing an assessment of the client and reviewing the client's EMR. (For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.)

Answer 33

Appendicitis - Pain location, temperature, GI concerns Crohn's Disease - Stool color, pain location, temperature, GI concerns

Question 34

(NGN) A nurse is caring for a client. Complete the following sentence by using the lists of options.

Answer 34

After reviewing the findings in the client's medical record, the nurse should first address the client's ABDOMINAL FINDINGS followed by the client's PAIN RATING

Question 35

(NGN) The nurse is providing care for the client. The nurse is planning care for the client. (For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.)

Answer 35

Anticipate - Obtain blood cultures, insert NG, obtain vitals Contraindicated - Bolus fluids

Question 36

(NGN) The nurse is providing care for the client. A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. Which of the following actions should the nurse take? Select the 3 actions that the nurse should take.

Answer 36

Administer gentamicin 100 mg IV. Administer client's PO medication with a sip of water. Ensure that the client has provided informed consent.

Question 37

The nurse is providing care for the client. A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.)

Answer 37

"I should schedule several rest periods throughout the day." "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit."

Question 38

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I should clean my toothbrush in the dishwasher once a month." B. "I should eat more fresh fruit and vegetables." C. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." D. "I will take my temperature once a day."

Answer 38

D. "I will take my temperature once a day."

Question 39

A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? A. Apply ice to the client's puncture wounds. B. Initiate corticosteroid therapy for the client. C. Keep the client's leg above heart level. D. Administer an opioid analgesic to the client.

Answer 39

D. Administer an opioid analgesic to the client.

Question 40

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? A. Try to walk at least three times per week for exercise. B. To increase stamina, walk for 5 min after fatigue begins. C. Take over-the-counter cough medicine for persistent cough. D. Use a salt substitute to reduce sodium intake.

Answer 40

A. Try to walk at least three times per week for exercise.

Question 41

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take calcium supplements so the medication will work better in my system." B. "I am taking this medication to increase my energy level." C. "This medication can cause my blood pressure to drop." D. "I will not need to restrict protein in my diet while taking this medication."

Answer 41

B. "I am taking this medication to increase my energy level."

Question 42

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A. Painless ulcerations on the ankles B. Hair loss on the lower legs C. No extremity pain when resting D. Rubor with elevation of the extremity

Answer 42

B. Hair loss on the lower legs

Question 43

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take my iron with a glass of milk." B. "I will take an antacid with my iron." C. "I will limit my intake of red meat." D. "I will eat more high-fiber foods."

Answer 43

D. "I will eat more high-fiber foods."

Question 44

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? A. Administer a placebo to the client without their knowledge. B. Instruct the client on alternative therapies for pain reduction. C. Tell the client not to worry about addiction to prescribed narcotics. D. Suggest the client receive a different opioid for pain reduction.

Answer 44

B. Instruct the client on alternative therapies for pain reduction.

Question 45

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL shouldthe nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 45

24 mL

Question 46

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? A. Total cortisol 0.9 mcg/dL (5 to 23 mcg/dL) B. Amylase 440 units/L (30 to 220 unit/L) C. Calcium 7.5 mg/dL (9 to 10.5 mg/dL) D. Troponin I 8 ng/mL (less than 0.03 ng/mL)

Answer 46

D. Troponin I 8 ng/mL (less than 0.03 ng/mL)

Question 47

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? A. Metoprolol B. Bupropion C. Atorvastatin D. Naproxen

Answer 47

D. Naproxen

Question 48

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? A. Remain with the client for the first 15 min of the infusion. B. Prime the blood administration IV tubing with lactated Ringer's solution. C. Verify the client's identity by using the client's room number prior to starting the transfusion. D. Infuse the unit of packed RBCs within 8 hr.

Answer 48

A. Remain with the client for the first 15 min of the infusion.

Question 49

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? A. Drink 240 mL (8 oz) of water after administration. B. Expect results in 4 to 6 hr. C. Take this medication before meals to increase appetite. D. Reduce dietary fiber intake to improve medication absorption.

Answer 49

A. Drink 240 mL (8 oz) of water after administration.

Question 50

(NGN) A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Answer 50

1. Administer oxygen via a nonrebreather mask. 2. Initiate IV therapy with a large-bore catheter. 3. Insert an NG tube. 4. Administer famotidine.

Question 51

(NGN) A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit"button for additional information about the client. There are three tabs that contain separate categories of data.) A. Disease processes B. Laboratory findings C. Current medications D. Family history

Answer 51

C. Current medications

Question 52

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? A. Keep the client's personal care items in the bathroom. B. Keep the overhead lights on in the client's bedroom while the client is sleeping. C. Remind the client to scan their complete range of vision during ambulation. D. Secure the client's extension cords under carpeting.

Answer 52

C. Remind the client to scan their complete range of vision during ambulation.

Question 53

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? A. Secure the straps firmly around the boot. B. Remove the device before showering. C. Use crutches with rubber tips. D. Adjust the screws to maintain alignment.

Answer 53

C. Use crutches with rubber tips.

Question 54

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? A. Decreased T cells B. Increased creatinine clearance C. Increased eosinophils D. Decreased viral load

Answer 54

D. Decreased viral load

Question 55

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

Answer 55

image is a smooth red/pink tongue --> glossitis white skin ombre in the center

Question 56

(NGN) A nurse is caring for a client. The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. (THINK: COW-BP)

Answer 56

(THINK: COW-BP) Chest x-ray Oxygen saturation level WBC count BUN level PCO₂ level

Question 57

(NGN) A nurse is caring for a client. The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Answer 57

Client is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache" Crackles heard in posterior lungs Client is diaphoretic

Question 58

(NGN) A nurse is caring for a client. A nurse is prioritizing client care. Complete the following sentence by using the lists of options.

Answer 58

The nurse should first address the client's OXYGEN SATURATION, followed by the client's TEMPERATURE.

Question 59

(NGN) A nurse is caring for a client. The nurse is planning care for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Answer 59

Anticipated - Obtain sputum, acetaminophen, cough and deep breathe, administer O2 Nonessential - Neuro checks, famotidine Contraindicated - Limit fluid intake

Question 60

(NGN) A nurse is caring for a client. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention.

Answer 60

Potassium level WBC count Temperature

Question 61

(NGN) A nurse is caring for a client. The nurse is reviewing the client's medical record from Day 5. (THINK: BROH) Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again.

Answer 61

Blood pressure 128/56 mm Hg Respiratory rate 20/min Oxygen saturation 95% on room air Heart rate 72/min

Question 62

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? A. Use pillows to support the client's head and neck. B. Offer opioid medication. C. Place a tracheostomy tray at the bedside. D. Place the client in semi-Fowler's position.

Answer 62

C. Place a tracheostomy tray at the bedside.

Question 63

A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet? A. 12 almonds B. One small banana C. 1 tbsp peanut butter D. 1/2 cup tomato juice

Answer 63

A. 12 almonds

Question 64

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? A. "This measures how much blood my heart is pumping." B. "This identifies if I have a defective heart valve." C. "This identifies if the pacemaker cells of my heart are working properly." D. "This measures the blood circulating to my heart muscle."

Answer 64

C. "This identifies if the pacemaker cells of my heart are working properly."

Question 65

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should thenurse identify as a desired outcome for this therapy? A. INR 1 (0.8 to 1.1) B. INR 2.5 (0.8 to 1.1) C. aPTT 45 seconds (30 to 40 seconds) D. aPTT 90 seconds (30 to 40 seconds)

Answer 65

B. INR 2.5 (0.8 to 1.1)

Question 66

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? A. Document that depolarization has occurred. B. Increase the pacemaker's voltage. C. Decrease the pacemaker's sensitivity. D. Check the placement of the ECG leads.

Answer 66

A. Document that depolarization has occurred

Question 67

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? A. Obtain ABGs. B. Administer propofol to the client. C. Instruct the client to allow the machine to breathe for them. D. Disconnect the machine and manually ventilate the client.

Answer 67

C. Instruct the client to allow the machine to breathe for them.

Question 68

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? A. Elevated blood pressure B. Dehydration C. Stress ulcers D. Hypernatremia

Answer 68

C. Stress ulcers

Question 69

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? A. Document the client's intake and output. B. Scan the bladder with a portable ultrasound. C. Pour warm water over the client's perineum. D. Perform a straight catheterization.

Answer 69

B. Scan the bladder with a portable ultrasound.

Question 70

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? A. "I will need to take antibiotics for 1 year." B. "My partner will need to take an antiviral medication." C. "My joints ache because I have Lyme disease." D. "I bruise easily because I have Lyme disease."

Answer 70

C. "My joints ache because I have Lyme disease."

Question 71

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? A. "It is just easier to let my partner administer my insulin." B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." C. "I'm concerned I won't be able to read my blood sugar level because the screen is so small." D. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."

Answer 71

B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror."

Question 72

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIS). Which of the following information should the nurse include in the teaching? A. Avoid foods that are high in ascorbic acid. B. Add oatmeal to the water when taking a tub bath. C. Urinate every 6 hr. D. Take daily cranberry supplements.

Answer 72

D. Take daily cranberry supplements.

Question 73

A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing? A. Weight loss of 1 kg in 1 week B. BMI 24 C. Urine output 25 mL/hr D. Report of 3/10 pain on a 0 to 10 pain scale

Answer 73

C. Urine output 25 mL/hr

Question 74

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.)

Answer 74

(THINK: VOL) Visual spatial deficits One-sided neglect Left hemianopsia

Question 75

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A. A client who is receiving preoperative teaching for a right knee arthroplasty. B. A client who states they will have difficulty obtaining a walker for home use. C. A client who reports an increase in pain following a left hip arthroplasty. D. A client who is having emotional difficulty accepting that they have a prosthetic leg.

Answer 75

A. A client who is receiving preoperative teaching for a right knee arthroplasty.

Question 76

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? A. Explain procedures as they occur to the client. B. Place personal items, such as pictures, at the client's bedside. C. Orient the client to their location once a shift. D. Encourage the family members to remain home until the client has adjusted.

Answer 76

B. Place personal items, such as pictures, at the client's bedside.

Question 77

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions A. Wear a mask. B. Wear a gown. C. Keep the client's room well-lit. D. Maintain the head of the bed at a 45° elevation.

Answer 77

A. Wear a mask.

Question 78

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? A. Nonrebreather mask B. Venturi mask C. Simple face mask D. Partial rebreather mask

Answer 78

A. Nonrebreather mask

Question 79

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? A. Obtain a sputum specimen to determine if there is colonization. B. Bathe the client using chlorhexidine solution. C. Place the client in droplet isolation. D. Restrict visits from the client's friends and family.

Answer 79

B. Bathe the client using chlorhexidine solution.

Question 80

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? A. Bounding pedal pulse B. Capillary refill less than 2 seconds C. Pain that increases with passive movement D. Areas of warmth on the cast

Answer 80

C. Pain that increases with passive movement

Question 81

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? A. The chest tube is draining serosanguineous fluid at 65 mL/hr. B. The client tolerates gentle milking of the tubing. C. Bubbling in the water seal chamber has ceased. D. There is tidaling in the water seal chamber.

Answer 81

C. Bubbling in the water seal chamber has ceased.

Question 82

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? A. Hydrocodone B. Bupropion C. Lactulose D. Warfarin

Answer 82

D. Warfarin

Question 83

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. B. Assist the client to start arm exercises 48 hr after surgery. C. Maintain the right arm in an extended position at the client's side when in bed. D. Place the client in a supine position for the first 24 hr after surgery.

Answer 83

A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.

Question 84

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? A. Report of sore throat B. Report of memory loss C. Alopecia D. Mucositis

Answer 84

A. Report of sore throat

Question 85

(NGN) A nurse is caring for a client. For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Answer 85

Emphysema - ABG results, RR, HR, Breath sounds, Cough Asthma - RR, breath sounds, cough Pneumonia - ABG, RR, temp, HR, breath, cough

Question 86

(NGN) A nurse is caring for a client in the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

Answer 86

Actions: Administer Morphine IV - Ensure client is NPO Condition: Cholecystitis Parameters: Monitor for rectal bleeding - Monitor for dark urine

Question 87

(NGN) A nurse is caring for a client who was just admitted from the emergency department (ED). Drag words from the choices below to fill in each blank in the following sentence.

Answer 87

The client is most likely experiencing ACUTE CHEST SYNDROME and PNEUMONIA.

Question 88

A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.

Answer 88

"I will need to do the breathing exercises every 1 to 2 hours after the surgery" "I will be sure to ask for pain medication before my knee starts to hurt too bad" "I will probably be going home with a walker"

Question 89

A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply.

Answer 89

Avoid drinking fluids with meals Eat several small meals Consume high-protein snacks Avoid highly seasoned foods

Question 90

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? A. "You will still have the urge to void." B. "You can apply an aspirin tablet to the pouch to reduce odor." C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." D. "You should use a moisturizing soap when washing the skin around the stoma."

Answer 90

C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma."