daniel

Question 1

The nurse is collecting a sterile urine specimen using a straight catheter tray for culture…. (Arrange from first action to last).

Answer 1

1. Drape the client in a recumbent position for privacy
2. Open the urinary catheterization tray
3. Don sterile gloves using aseptic technique
4. Use forceps and swaps to clean the urinary meatus

Question 2

A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last)

Answer 2

1. Call the rapid response team to assist
2. Move the crash cart to the client room
3. Notify the client’s healthcare provider
4. Inform the family of the critical situation

Question 3

A client presents to the labor and delivery unit, screaming “THE BABY IS COMING” which action should the nurse implement first.

Answer 3

Observe the perineum

Question 4

The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse’s response should include which information? (Select all that apply)

Answer 4

The husband cannot sign the consent for the client, her signature is required
The client’s specific wishes should be discussed with her healthcare provider
The healthcare team will formulate a plan of care to keep the client comfortable

Question 5

A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

Answer 5

Schedule the client for the chest radiography
Obtain a sputum for acid fast bacillus (AFB) testing
Place a mask on the client until he is moved to isolation

Question 6

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Answer 6

Document the ongoing wound healing.

Question 7

The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

Answer 7

8

Question 8

The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, “10 mEq/5ml.” how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)

Answer 8

12.5

Question 9

An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

Answer 9

0.4

Question 10

A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Answer 10

Provide the man and his mother with a copy of the Patient’s Bill of Rights

Question 11

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Answer 11

Ask the older brother how he felt during the incident.

Question 12

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply)

Answer 12

Close car windows and use air conditioner
Avoid sudden changes in temperature
Keep away from pets with long hair
Stay indoors when grass is being cut

Question 13

Which assessment finding indicates to the nurse a client’s readiness for pulmonary function tests?

Answer 13

Expresses an understanding of the procedure.

Question 14

A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?

Answer 14

Infuse sodium chloride 0.9% (normal saline)

Question 15

The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?

Answer 15

Contractions of the sternocleidomastoid muscle

Question 16

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Answer 16

Monitor mental status.

Question 17

A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?

Answer 17

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo

Question 18

Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

Answer 18

47

Question 19

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)

Answer 19

Avoid eating grapefruit or drinking grapefruit juice
Report changes in the use of daily supplements
Notify you heal care provider if your skin looks yellow

Question 20

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

Answer 20

Stroke secondary to hemorrhage

Question 21

The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Answer 21

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

Question 22

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices?

Answer 22

They decrease the risk for joint trauma

Question 23

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Answer 23

Confirm the necessity for continued use of the CVC.

Question 24

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care?

Answer 24

Ensure proper alignment of the leg in traction.

Question 25

The nurse is evaluating a client’s symptoms, and formulates the nursing diagnosis, “high risk for injury due to possible urinary tract infection.” Which symptoms indicate the need for this diagnosis?

Answer 25

Fever and dysuria.

Question 26

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Answer 26

Maintain both lower extremities elevated on pillows.

Question 27

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

Answer 27

Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

Question 28

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client’s plan of care?

Answer 28

Teach family proper range of motion exercises.

Question 29

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

Answer 29

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

Question 30

An older adult male with emphysema who continues to smoke cigarettes returns to the medical unit after a physical therapy session, and is complaining of being short of breath. He nurse notes that the client is lying supine with the head of the bed elevated to 45 degrees, Oxygen is flowing via nasal cannula at 3L/minute, his pulse oximetry is 88%, his respiratory rate is 14 breaths/minute, and his vital signs are stable. Which intervention should the nurse implement?

Answer 30

Administer a prescribed albuterol inhaler

Question 31

A female client reports that she drank a liter of a solution to cleanse her intestines…immediately. How many ml of fluid intake should the nurse document? Whole number

Answer 31

760

Question 32

The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin…medication?

Answer 32

Push the undiluted Dextrose slowly through the currently infusion IV

Question 33

A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Answer 33

Urine output 20 ml/hour

Question 34

In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

Answer 34

Serum creatinine

Question 35

A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He had full thickness burns to his lower torso and extremities. Before a change to his legs which intervention is most important for the nurse to implement?

Answer 35

Maintain strict aseptic technique

Question 36

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?

Answer 36

Distal pulse intensity

Question 37

The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Answer 37

Elevate the presenting part off the cord

Question 38

The mother of a one-month-old boy born at home brings the infant to his first well…was born two weeks after his due date, and that he is a “good, quiet baby” who almost…hypothyroidism, what question is most important for the nurse to ask the mother?

Answer 38

Is your son sleepy and difficult to feed?

Question 39

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

Answer 39

An older client post-stroke who is aphasic with right-sided hemiplegia

Question 40

Following a gunshot wound to the abdomen, a young adult male had an emergency bowel…Multiple blood products while in the operating room. His current blood pressure is 78/52…He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values…Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first?

Answer 40

Transfuse packed red blood cells

Question 41

After checking the fingerstick glucose at 1630, what action should the nurse implement?

Answer 41

Administer 8 units of insulin aspart SubQ

Question 42

Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscule…Which finding warrants immediate intervention by the nurse?

Answer 42

Evidence of hypoventilation

Question 43

An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter’s request, the client is intubated and…Which nursing intervention has the highest priority?

Answer 43

Determine if the client has an executed living will

Question 44

The nurse determines that a client’s pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding?

Answer 44

Pupils reactive to accommodation

Question 45

Which nursing intervention has the highest priority for a multigravida who delivered…

Answer 45

Assess fundal tone and lochia flow

Question 46

A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being…18 months-old child and lives in a rural area. Her husband takes the family car to work daily…transportation during the day. What intervention is most important for the nurse to implement?

Answer 46

Schedule a weekly home visit to draw hCG values

Question 47

A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

Answer 47

I’ll change your assignment, but let’s talk about you a nurse should respond to this kind of client

Question 48

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned in the unit following lumbar spinal surgery, What action should the nurse implement immediately?

Answer 48

Test the fluid on the dressing for glucose using a chemstrip

Question 49

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Answer 49

Obtain a clean catch mid-stream specimen

Question 50

A client’s subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

Answer 50

Collect a clean-catch specimen

Question 51

A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give the healthcare provider?

Answer 51

Reassess readiness for SNF transfer.

Question 52

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)

Answer 52

Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.

Question 53

The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Answer 53

Large amounts of fluid and electrolyte replacement.

Question 54

A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet?

Answer 54

One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.

Question 55

Which class of drugs is the only source of a cure for septic shock?

Answer 55

Antiinfectives

Question 56

care instructions to the mother, which statement by the child’s mother indicates that she understands home care treatment to promote pulmonary functions?

Answer 56

Chest physiotherapy should be performed twice a day before a meal.

Question 57

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?

Answer 57

Fresh horseradish

Question 58

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client’s pain?

Answer 58

Does your pain occur when walking short distances?

Question 59

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

Answer 59

Place the id bands on the infant and mother

Question 60

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

Answer 60

Advise the client to empty her bladder fully when she first voids

Question 61

A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only) 3 ml/hour

Answer 61

3ml per hr

Question 62

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Answer 62

Destruction of joint cartilage

Question 63

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client’s GCS score has been 14. What does this GCS finding indicate about the client?

Answer 63

Neurologically stable without indications of an increased ICP

Question 64

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Answer 64

Ineffective coping related to denial

Question 65

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

Answer 65

Document the extent of the bruising in the medical record

Question 66

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

Answer 66

Lower the left arm below the level of the heart

Question 67

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

Answer 67

Cold sensitivity

Question 68

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client’s serum laboratory values requires intervention by the nurse?

Answer 68

Total calcium 5.0 mg/dl

Question 69

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

Answer 69

Explore the client’s reasons for wanting to be discharged

Question 70

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

Answer 70

Fetal heart rate of 200 beats/minute

Question 71

A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife’s birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

Answer 71

Continue to monitor the client’s blood pressure hourly

Question 72

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client’s teaching plan?

Answer 72

Take on an empty stomach with a full glass of water

Question 73

The nurse is assessing a female client’s blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next?

Answer 73

Wait 1 minute and palpate the systolic pressure before auscultating again.

Question 74

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Answer 74

Ask the client about gastrointestinal pain

Question 75

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?

Answer 75

Review the staff nurse job description to ensure that it is clear, accurate, and current

Question 76

A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

Answer 76

Institute coughing and deep breathing protocols

Question 77

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next?

Answer 77

Ask for a full explanation from the interpreter of the witnessed discussion

Question 78

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

Answer 78

Place a portable toilet next to the bed

Question 79

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

Answer 79

Notify the healthcare provider

Question 80

While taking vital signs, a critically ill male client grabs the nurse’s hand and ask the nurse not to leave. What action is best for the nurse to take?

Answer 80

Pull up a chair and sit beside the client’s bed

Question 81

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

Answer 81

Viral meningitis whose temperature changed from 101 F to 102 F

Question 82

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

Answer 82

1000, 1600, 2200, 0400

Question 83

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

Answer 83

1000, 1600, 2200, 0400

Question 84

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

Answer 84

Asses for contraindications for thrombolytic therapy

Question 85

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client’s medical history?

Answer 85

Frequency of laxative use for chronic constipation

Question 86

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Answer 86

Recommend weight bearing physical activity

Question 87

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

Answer 87

Blood pressure 90/76 mm Hg

Question 88

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client’s plan of care?

Answer 88

Evaluate daily blood clotting factors

Question 89

The nurse enters a client’s room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Answer 89

Evaluate the oxygen saturation

Question 90

During a clinic visit, a client with a kidney transplant ask, “What will happen if chronic rejection develops?” which response is best for the nurse to provide?

Answer 90

Dialysis would need to be resumed if chronic rejection becomes a reality

Question 91

The nurse enters a client’s room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

Answer 91

Place the side rails in an up position

Question 92

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

Answer 92

Leakage around catheter insertion site

Question 93

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

Answer 93

Chest pain and dysrhythmia

Question 94

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste “bitter”. He complains that he simply has no appetite. What action should the nurse implement?

Answer 94

Suggest the use of alternative sources of protein such as dairy products and nuts

Question 95

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make?

Answer 95

Contact the healthcare provider immediately to report the laboratory value regardless of the advice

Question 96

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Answer 96

Notify the healthcare provider of the client’s change in mental status.
Include q2 hour’s reorientation in the client’s plan of care.

Question 97

An older male comes to the clinic with a family member. When the nurse attempts to take the client’s health history, he does not respond to questions in a clear manner. What action should the nurse implement first?

Answer 97

Assess the surroundings for noise and distractions.

Question 98

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?

Answer 98

Raise the client’s legs and feet

Question 99

A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

Answer 99

A mother with an infected episiotomy

Question 100

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Answer 100

Observe for unilateral swelling

Question 101

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?

Answer 101

Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

Question 102

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client’s history is a possible contraindication for the use of HRT?

Answer 102

Her mother and sister have a history of breast cancer

Question 103

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is “starving” because he has had no “real food” since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?

Answer 103

Auscultate bowel sounds in all four quadrants

Question 104

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Answer 104

A family member of a client with dementia who has been missing for five hours

Question 105

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?

Answer 105

Notify the healthcare provider and obtain a tracheostomy tray

Question 106

An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant’s heart rate drops to 80 beats / minute. What action should the nurse take?

Answer 106

Slow the feeding and monitor the infant’s response.

Question 107

While removing staples from a male client’s postoperative wound site, the nurse observes that the client’s eyes are closed and his face and hands are clenched. The client states, “I just hate having staples removed.” After acknowledging the client’s anxiety, what action should the nurse implement?

Answer 107

Attempt to distract the client with general conversation

Question 108

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?

Answer 108

Epinephrine Injection, USP IV

Question 109

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?

Answer 109

Evaluate both client’s pain using a standardized pain scale

Question 110

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Answer 110

Administer the medication as prescribed with a glass of water

Question 111

Which client should the nurse assess frequently because of the risk for overflow incontinence?

Answer 111

A client who is confused and frequently forgets to go to the bathroom

Question 112

A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Answer 112

Ensure that the infant’s crib mattress is firm

Question 113

Which intervention should the nurse include in the plan of care for a child with tetanus?

Answer 113

Minimize the amount of stimuli in the room

Question 114

A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete post-anesthesia scoring system. What intervention should nurse implement?

Answer 114

Transfer the client to the surgical floor.

Question 115

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Answer 115

Reinforce the importance of annual papanicolaou (Pap) smears.

Question 116

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Answer 116

Establish a structured routine for the client to follow.

Question 117

A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Answer 117

Ventricular arrhythmias.

Question 118

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Answer 118

Encourage the client to eat finger foods.

Question 119

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

Answer 119

Bowel patterns

Question 120

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Answer 120

Contact the medical records department supervisor.

Question 121

A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer 121

83

Question 122

A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement?

Answer 122

Palpate at the radial pulse site with the pads of two or three fingers

Question 123

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Answer 123

Reposition the client with the head of the bed elevated.

Question 124

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Answer 124

Hold oral intake until swallow evaluation is done.

Question 125

The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If round is required, round to the nearest tenth.)

Answer 125

1.5

Question 126

A vacuum-assisted closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?

Answer 126

Ensure the transparent dressing has no tears that might create vacuum leaks

Question 127

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of “Ineffective airway clearance related to thick pulmonary secretions.” Which intervention is most important for the nurse to include in the client’s plan of care?

Answer 127

Increase fluid intake to 3,000 ml/daily

Question 128

Thenurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Answer 128

Decreases the amount of HCL secretion by the parietal cells in the stomach

Question 129

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug’s effectiveness?

Answer 129

Hemoglobin A1C (HbA1C) reading less than 7%

Question 130

An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420 mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous (IV), the client immediately begins to vomit. What action should the nurse implement first?

Answer 130

Turn the client to a lateral position

Question 131

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing diagnosis for this client?

Answer 131

Anxiety

Question 132

A male client with impaired renal function who takes ibuprofen daily for chronic arthritis…gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours?

Answer 132

Evaluate daily serial renal laboratory studies for progressive elevations

Question 133

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?

Answer 133

Remain upright after taking the medication

Question 134

A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement?

Answer 134

Determine how the client is cared for when caregiver is not present

Question 135

A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

Answer 135

New onset of purple skin lesions.

Question 136

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Answer 136

Ensure that no dependent loops are present in the tubing.

Question 137

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client’s appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Answer 137

Anxiety related to fear of suffocation.

Question 138

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client’s a plan of care?

Answer 138

Provide daily care of tong insertion sites using saline and antibiotic ointment

Question 139

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Answer 139

Determine the client’s vital sign.

Question 140

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high-pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

Answer 140

No wheezing upon auscultation of the chest.

Question 141

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

Answer 141

During acute illness

Question 142

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Answer 142

Tell all their assigned clients to stay in their rooms.

Question 143

The healthcare provider changes a client’s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?

Answer 143

Administer the medication via the oral route as prescribed

Question 144

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by “too much gas buildup” the client’s abdomen is distended. Which prescribed PRN medication should the nurse administer?

Answer 144

Simethicone (Mylicon)

Question 145

A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client’s teaching plan?

Answer 145

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

Question 146

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Which intervention is most important for the nurse to implement?

Answer 146

Remove cigarettes for the client’s room

Question 147

A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

Answer 147

1000 units/hour

Question 148

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

Answer 148

The family reports a great reduction in client’s manic behavior

Question 149

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?

Answer 149

Assess IV site frequently for signs of extravasation

Question 150

A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

Answer 150

7

Question 151

A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)

Answer 151

1.6

Question 152

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client’s medical history?

Answer 152

Frequency of laxative use for chronic constipation

Question 153

The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

Answer 153

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

Question 154

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Answer 154

Digoxin

Question 155

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Answer 155

Supervise a newly hired graduate nurse during an admission assessment.

Question 156

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

Answer 156

Ask the client what he is thinking about at his time.

Question 157

The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Answer 157

Administer a prescribed analgesia for pain.

Question 158

A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Answer 158

Use sunblock or protective clothing when outdoors.

Question 159

The rapid response team’s detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Answer 159

Perform bilateral chest auscultation.

Question 160

After administering an antipyretic medication. Which intervention should the nurse implement?

Answer 160

Encouraging liberal fluid intake

Question 161

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Answer 161

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

Question 162

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Answer 162

Determine client’s pulse, blood pressure, and respirations

Question 163

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

Answer 163

Raise the head of the bed to a Fowler’s position and support his arms with a pillow

Question 164

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?

Answer 164

Administer the analgesic as requested

Question 165

The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)

Answer 165

12160

Question 166

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

Answer 166

Surgeon needs to see client immediately to evaluate the situation

Question 167

When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

Answer 167

Hold the thermometer in place

Question 168

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive…medication therapy, the nurse notices the client has more energy, is giving her belongings…mood. Which intervention is best for the nurse to implement?

Answer 168

Ask the client if she has had any recent thoughts of harming herself

Question 169

An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue…Medications. Which medication provides the greatest threat to this client?

Answer 169

Magnesium hydroxide (Maalox)

Question 170

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?

Answer 170

Administer the analgesic as requested

Question 171

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?

Answer 171

Ask the wife to stop and assess the client’s swallowing reflex

Question 172

A woman just learned that she was infected with Helicobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?

Answer 172

Encourage screening for a peptic ulcer

Question 173

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Answer 173

Teach tracheal suctioning techniques

Question 174

The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Answer 174

Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

Question 175

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?

Answer 175

Establish trust with community leaders and respect cultural and family values

Question 176

The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired movements will worsen as the child grows. Which response provides the best explanation?

Answer 176

Brain damage with CP is not progressive but does have a variable course

Question 177

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Answer 177

Respiratory apnea of 30 seconds

Question 178

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean…tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the…should the nurse take?

Answer 178

Explain that the hand rub can be completed in less than 2 minutes

Question 179

An adolescent’s mother calls the clinic because the teen is having recurrent vomiting and…Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag…With aspirin. Which nursing intervention has highest priority?

Answer 179

Instruct the mother to take the teen to the emergency room

Question 180

An older female client tells the nurse that her muscles have gradually been getting weak…what is the best initial response by the nurse?

Answer 180

Ask the client to describe the changes that have occurred

Question 181

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Answer 181

Report weight gain of 2 pounds (0.9kg) in 24 hours

Question 182

Which problem, noted in the client’s history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Answer 182

Aural migraine headaches.

Question 183

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Answer 183

Be alert for possible cross-sensitivity to cephalosporin agents.

Question 184

A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

Answer 184

The client’s need for pain medication should be determined.

Question 185

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Answer 185

Explain the reason for using only non-narcotics.

Question 186

The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Answer 186

Weigh the client and report any weight gain.
Report any client complaint of pain or discomfort.
Note and report the client’s food and liquid intake during meals and snacks.

Question 187

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client’s plan of care?

Answer 187

Medicate as needed for pain and anxiety.

Question 188

A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Answer 188

Maternal pulse rate of 162 beats per min

Question 189

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?

Answer 189

Decrease prevalence of glaucoma in the population.

Question 190

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Answer 190

Convey to the client that birth is imminent.

Question 191

To evaluate the effectiveness of male client’s new prescription for ezetimibe, which action should the clinic nurse implement?

Answer 191

Remind the client to keep his appointments to have his cholesterol level checked.

Question 192

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

Answer 192

Fall prevention measures.

Question 193

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

Answer 193

A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools

Question 194

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)…which breakfast selection by the client indicates effective learning?

Answer 194

Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

Question 195

A client with a postoperative wound that eviscerated yesterday has an elevated temperature…most important for the nurse to implement?

Answer 195

Obtain a wound swab for culture and sensitivity

Question 196

The nurse is reinforcing home care instructions with a client who is being discharged following…prostate (TURP). Which intervention is most important for the nurse to include in the client…

Answer 196

Report fresh blood in the urine

Question 197

The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Answer 197

Complain of headaches and stiff neck

Question 198

A male client with rheumatoid arthritis is schedule for a procedure in the morning. The…unable to complete the procedure because of early morning stiffness. Which intervention…implement?

Answer 198

Assign a UAP to assist the client with a warm shower early in the morning

Question 199

A client with a new diagnosis of Raynaud’s disease lives alone. Which instruction should the nurse include in the client’s discharged teaching plan?

Answer 199

Keep room temperature 80

Question 200

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement?

Answer 200

Infuse a rapid IV normal saline bolus

Question 201

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

Answer 201

Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

Question 202

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother

Answer 202

Withhold this dose

Question 203

When checking a third grader’s height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

Answer 203

Refer child to the family healthcare provider

Question 204

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.)

Answer 204

33ml

Question 205

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care?

Answer 205

Monitor blood pressure frequently

Question 206

A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Answer 206

Ask the client to discuss “do not resuscitate” with her healthcare provider

Question 207

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Answer 207

Obtain a list of medications taken for cardiac history

Question 208

The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

Answer 208

Murmur

Question 209

The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)

Answer 209

0.4

Question 210

A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Answer 210

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour

Question 211

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

Answer 211

Have you noticed any changes in your fingernails?

Question 212

Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?

Answer 212

Advise the client that assignments are not based on clients requests

Question 213

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

Answer 213

Place the implant in a lead container using long-handled forceps

Question 214

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?

Answer 214

Tell the client that the nurse will be back to talk to her after medications are given

Question 215

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement?

Answer 215

Document the assessment data

Question 216

A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan?

Answer 216

Further evaluation involving surgery may be needed

Question 217

During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

Answer 217

Check the client for lacerations or fractures

Question 218

At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Answer 218

Inform the anesthesia care provider

Question 219

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

Answer 219

Listen with the bell at the same location

Question 220

A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Answer 220

Medicare

Question 221

A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

Answer 221

Toasted wheat bread and jelly

Question 222

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?

Answer 222

Foods sweetened with aspartame

Question 223

Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Answer 223

Direct the nurse to continue the surgical hand scrub for a 5 minute duration

Question 224

A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Answer 224

Baked apples topped with dried raisins

Question 225

Which action should the school nurse take first when conducting a screening for scoliosis?

Answer 225

Inspect for symmetrical shoulder height.

Question 226

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

Answer 226

Supervised a newly hired graduate nurse during an admission assessment

Question 227

The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Answer 227

Obtain a detailed report from the nurse transferring the client.

Question 228

The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer’s diseases. The client’s wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?

Answer 228

Suggest enrolling the client in adult daycare instead of rotating among family.

Question 229

A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

Answer 229

Evaluate the urine osmolality and the serum osmolality values.

Question 230

A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Answer 230

Report the client’s jaw pain to the healthcare provider.

Question 231

A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?

Answer 231

Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

Question 232

Which intervention should the nurse implement for a client with a superficial (first degree) burn?

Answer 232

Place wet cloths on the burned areas for short periods of time.

Question 233

What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Answer 233

Achieve satisfactory pain control.

Question 234

An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take?

Answer 234

Encourage the client to describe the pain.

Question 235

An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

Answer 235

Assign a practical nurse (LPN) to determine if an apical radial deficit is present

Question 236

After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan?

Answer 236

Encourage a low-carbohydrate and high-protein diet

Question 237

A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Answer 237

Observe the antecubital fossa for inflammation.

Question 238

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply

Answer 238

White blood cell (WBC) count

Sputum culture and sensitivity

Question 239

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Answer 239

Sitting up and leaning forward

Question 240

A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

Answer 240

Rented movies and borrowed books to use while passing time at home

Question 241

Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Answer 241

Eat small meal throughout the day to avoid a full stomach.

Question 242

A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Answer 242

Digitally check the client for a fecal impaction

Question 243

After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

Answer 243

Bilateral Wheezing.

Question 244

The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response?

Answer 244

Inflammation of the mucous membrane & bronchospasm

Question 245

A 10 year old who has terminal brain cancer asks the nurse, “What will happen to my body when I die?” How should the nurse respond?

Answer 245

The heart will stop beating & you will stop breathing.”

Question 246

Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis?

Answer 246

Bagel with jelly and skim milk

Question 247

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?

Answer 247

An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist restraints applied

Question 248

The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

Answer 248

Determine which side of the body is weak.

Question 249

The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

Answer 249

Measure hourly urinary output.

Question 250

When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

Answer 250

Schedule an appointment for an out-patient psychosocial assessment.

Question 251

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

Answer 251

Explore client’s readiness to discuss the situation.

Question 252

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication?

Answer 252

Divalproex.

Question 253

A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Answer 253

Serum lithium level of 1.6 mEq/L or mmol/l (SI)

Question 254

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

Answer 254

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

Question 255

The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?

Answer 255

Literacy level

Question 256

A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?

Answer 256

Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.

Question 257

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer’s at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Answer 257

Serum potassium level of 3.1 mEq/L or mmol/L (SI)

Question 258

The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Answer 258

Yogurt and/or buttermilk.

Question 259

Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will “finally go away.” How should the nurse respond?

Answer 259

Assist the client in developing a goal of managing the pain

Question 260

One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these finding, what is the client’s greatest risk?

Answer 260

Neurovascular and circulation compromise related to compartment syndrome.

Question 261

The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Answer 261

Clear fluid leaking from the nose.

Question 262

A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which pathophysiological mechanism supports this response?

Answer 262

Temporary vasodilation

Question 263

While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement?

Answer 263

Promptly remove the arterial catheter from the radial artery.

Question 264

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Answer 264

Rapid onset of decreased level of consciousness.

Question 265

The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Answer 265

Position a firm wedge to support pelvis and thorax at 30 degree tilt.

Question 266

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?

Answer 266

Observe the wound for dehiscence

Question 267

A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

Answer 267

Complete pre-infusion checklist

Question 268

The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

Answer 268

1.9

Question 269

A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).

Answer 269

0.4

Question 270

The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

Answer 270

75

Question 271

The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide?

Answer 271

Stop using the ointment and encourage complete drying of the feet and wearing clean socks.

Question 272

The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Answer 272

Observe the amount of urine in the client’s urinary drainage bag

Question 273

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan?

Answer 273

Report any signs of cloudy urine output.

Question 274

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Answer 274

Tented skin turgor.

Question 275

After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?

Answer 275

Apply light pressure over the area.

Question 276

The nurse enters a client’s room and observes the client’s wrist restraint secured as seen in the picture. What action should the nurse take?

Answer 276

Reposition the restraint tie onto the bedframe.

Question 277

The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?

Answer 277

Evacuate each infant with mother via wheelchair

Question 278

The healthcare provider prescribes heparin protocol at 18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.)

Answer 278

12

Question 279

A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?

Answer 279

The child should avoid eating homemade cookies and cupcakes during parties

Question 280

A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2…what is the pathophysiological basis for this ventilator settings?

Answer 280

Hypocapnea reduces ICP

Question 281

During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?

Answer 281

Prepare for the endotracheal tube to be repositioned

Question 282

A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?

Answer 282

Hyperextended with neck supported by a rolled towel.

Question 283

An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply

Answer 283

History of hypertension.

Family health history.

Question 284

A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result…dealing with the healthcare provider. What action should the nurse-manager implement?

Answer 284

Plan an interdisciplinary staff meeting to develop strategies to enhance client care

Question 285

A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter’s protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother’s comment?

Answer 285

Explain that a protruding abdomen is typical for toddlers

Question 286

A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?

Answer 286

Unresponsive to painful stimuli

Question 287

A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child’s skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

Answer 287

Administered Nebulized Epinephrine

Question 288

The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?

Answer 288

Flex the client’s head with chin to the chest and insert.

Question 289

The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client’s weight is accurate?

Answer 289

Ensure that the scale is calibrated before a weight is obtained

Question 290

The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingerstick to obtain a client’s blood glucose. Prior to sticking the client’s finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take?

Answer 290

Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.

Question 291

An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?

Answer 291

Your blood pressure is a little high. You need to have it rechecked within one week

Question 292

While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated….persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

Answer 292

T4 levels in newborns

Question 293

After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?

Answer 293

Place one hand on top of the other and interlace the fingers

Question 294

A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?

Answer 294

Allow the infant to rest before feeding

Question 295

While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

Answer 295

Notify the employee health nurse.

Question 296

A nurse receives a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

Answer 296

Allow time for the behavior and then redirect the clients to other activities

Question 297

The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?

Answer 297

Place client in Trendelenburg position on the left side.

Question 298

The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-year-old client with… Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?

Answer 298

Peak and through levels has not been drawn since the tobramycin was started

Question 299

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate…through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Answer 299

Instruct the client to keep the left leg straight
Observe the insertion site for a hematoma
Circle first noted drainage on the dressing

Question 300

A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

Answer 300

Urinary output of 25mL per hour

Question 301

A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

Answer 301

Human source grafts require monitoring for signs of graft rejection

Question 302

The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, ‘stop I can’t hold anymore.” What action should the nurse take?

Answer 302

Clamp the tubing and instruct the client to breathe deeply before continuing.

Question 303

A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?

Answer 303

Diminished left lower lobe sounds

Question 304

Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse’s decision to report this finding to the healthcare provider?

Answer 304

Oliguria signals tubular necrosis related to hypoperfusion

Question 305

A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?

Answer 305

Skills of staff and client acuity

Question 306

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

Answer 306

Explain that the client may be placed in five positions

Question 307

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke?

Answer 307

Inability to close the affected eye, raise brow, or smile

Question 308

The nurse is teaching a client how to perform colostomy irrigations. When observing the client’s return demonstration, which action indicated that the client understood the teaching?

Answer 308

Keeps the irrigating container less than 18 inches above the stoma

Question 309

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

Answer 309

An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control

Question 310

A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

Answer 310

Determine if she can ask for support from family, friend, or the baby’s father.

Question 311

During an annual physical examination, an older woman’s fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?

Answer 311

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

Question 312

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Answer 312

Stop the normal saline infusion

Question 313

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with…daily leaving. When making this assignment, which instruction is most important for the nurse to do?

Answer 313

Place a washcloth in the sink while cleaning the dentures

Question 314

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?

Answer 314

Encourage use of analgesics before position change

Question 315

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse …. The client provides the nurse with a living will and DNR. What action should the nurse implement?

Answer 315

Obtain a prescription for DNR

Question 316

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

Answer 316

The body cells develop resistance to the action of insulin.

Question 317

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Answer 317

Instruct the client to keep the left leg straight
Observe the insertion site for a hematoma
Circle first noted drainage on the dressing

Question 318

A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

Answer 318

Risk for self-directed violence related to impulsive actions

Question 319

A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Answer 319

Contact the regional organ procurement agency

Question 320

The nurse should teach the client to observe which precaution while taking dronedarone?

Answer 320

Avoid grapefruits and its juice

Question 321

A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.

Answer 321

Maintain contact transmission precaution

Question 322

A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take?

Answer 322

Administer Naxolone IV

Question 323

A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?

Answer 323

Do not get pregnant for at least 3 months

Question 324

The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

Answer 324

45

Question 325

During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client’s privacy. What is the best initial nursing action for the nurse to implement?

Answer 325

Instruct the scrub nurse to re-drape the client

Question 326

The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond?

Answer 326

Offer to go with the family members to view the body.

Question 327

The nurse is conducting the initial assessment of an ill client who is from another culture…. What response should the nurse provide?

Answer 327

“What practices do you believe will help you heal?”

Question 328

The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP?

Answer 328

Disconnect the NG suction so the client can ambulate in the hallway

Question 329

The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents… holding the child as death approaches. Which intervention is most important for the nurse?

Answer 329

Notify nursing supervisor and hospital chaplain of the child’s impending death.

Question 330

The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child’s diagnosis?

Answer 330

“I couldn’t get my son’s socks and shoes on this morning”

Question 331

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation… is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What…

Answer 331

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded

Question 332

A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?

Answer 332

Instill beractant 100 mg/kg in endotracheal tube.

Question 333

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Answer 333

Moderate amount of foul-smelling lochia.

Question 334

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client’s compliance with self-care?

Answer 334

Have the client vocalize the instructions provided.

Question 335

A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only).

Answer 335

18

Question 336

The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

Answer 336

2,500

Question 337

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?

Answer 337

Determine the infant’s blood sugar level

Question 338

A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive…rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?

Answer 338

Obtain a pulse oximeter reading

Question 339

During a 26-week gestation prenatal exam, a client reports occasional dizziness…What intervention is best for the nurse to recommend to this client?

Answer 339

Lie on the left or right side when sleeping or resting

Question 340

Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is… the priority?

Answer 340

Have a meconium aspirator available at delivery

Question 341

A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy…Which action should the nurse instruct the parents to take if the child begins to vomit?

Answer 341

Continue giving ORS frequently in small amounts

Question 342

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer’s at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Answer 342

Serum potassium level of 3.1 mEq/L or mmol/L (SI)

Question 343

Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?

Answer 343

Place the client on fall precautions

Question 344

Based on the information provided in this client’s medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

Answer 344

Continue to monitor the progress of labor.