FInal

Question 1

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process?

a. Discuss the risks of the procedure with the client.
b. Explain alternatives to the procedure to the client.
c. Confirm that the client is competent to sign for the procedure.
d. Inform the client about what will occur during the procedure.

Answer 1

c. Confirm that the client is competent to sign for the procedure.

Question 2

A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first?

a. Check the client’s airway.
b. Check the client’s blood pressure.
c. Check the client’s level of consciousness.
d. Check the client’s level of pain.

Answer 2

a. Check the client’s airway.

Question 3

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

a. Replace the catheter every 3 days.
b. Check the catheter tubing for kinks or twisting.
c. Irrigate the catheter once each shift.
d. Clean the perineal area with an antiseptic solution daily.

Answer 3

b. Check the catheter tubing for kinks or twisting.

Question 4

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

a. Report of feeling pressure
b. Tenderness over the symphysis pubis
c. Distended bladder
d. Voiding 30 ml frequently - Dysuria

Answer 4

a. Report of feeling pressure
c. Distended bladder
d. Voiding 30 ml frequently - Dysuria

Question 5

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for more teaching?

a. “I will need to drink apple cider vinegar each day.”
b. “I will need to wipe my perineal area from back to front after urination.”
c. “I need to drink 8 cups of liquid each day.
d. “I will need to empty my bladder regularly and completely.”

Answer 5

b. “I will need to wipe my perineal area from back to front after urination.”

Question 6

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?

a. Urinary retention
b. Low back pain
c. Incontinence
d. Confusion

Answer 6

d. Confusion

Question 7

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following risk factors should the nurse include in the teaching?

a. “I will use different hand towels than others in my home.”
b. “I will wash my hands using an alcohol-based cleanser.”
c. “I can continue to prepare meals for my family.”
d. “I know that this virus is transmitted by contact with my blood.”

Answer 7

a. “I will use different hand towels than others in my home.”

Question 8

A nurse is teaching a client following a cystoscopy about his new prescription for tamsulosin. Which of the following adverse effects should the nurse include in the teaching?

a. Temporary loss of libido.
b. Dizziness.
c. Bradycardia
d. Burning with urination

Answer 8

b. Dizziness.

Question 9

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

a. Protein in the urine
b. Dehydration
c. Iron Deficiency
d. Obesity

Answer 9

b. Dehydration

Question 10

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?

a. “I drink at least 2 quarts of fluid every day.”
b. “The last time I voided it was painful and red-tinged.”
c. “My period ended 2 days ago.”
d. “I don’t eat shellfish because it gives me hives.”

Answer 10

d. “I don’t eat shellfish because it gives me hives.”

Question 11

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24hrs. Which of the following actions is the nurse’s priority?

a. monitor intake and output
b. strain the urine
c. administer pain meds
d. administer an antiemetic

Answer 11

c. administer pain meds

Question 12

A nurse is planning care for a client who is scheduled for extracorporeal shock-wave lithotripsy (ESWL). The nurse should plan to monitor the client for which of the following adverse effects of ESWL?

Answer 12

Bruising

Question 13

A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching?

a. “You should limit fluids for 12 hr following the procedure.”
b. “You may have pink-tinged urine after this procedure.”
c. “You can eat a full liquid meal up to 1 hour before the procedure.”
d. “You will be placed on your right side during the procedure.”

Answer 13

b. “You may have pink-tinged urine after this procedure.”

Question 14

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?

a. Take phenazopyridine for at least 7 days.
b. Phenazopyridine may cause photosensitivity.
c. Phenazopyridine may change the urine color.
d. Take phenazopyridine before sexual intercourse.

Answer 14

c. Phenazopyridine may change the urine color.

Question 15

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?

a. Sudden decrease in abdominal pain
b. Absent Rovsing’s sign
c. Flaccid abdomen
d. Low-grade fever

Answer 15

a. Sudden decrease in abdominal pain

Question 16

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse question?

a. Maintain NPO status.
b. Monitor oral temperature every 4 hr.
c. Medicate the client for pain every 4 hr as needed.
d. Administer sodium biphosphate/sodium phosphate (Fleet Enema) today

Answer 16

d. Administer sodium biphosphate/sodium phosphate (Fleet Enema) today

Question 17

A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the clients diet?

Answer 17

Roast turkey

Question 18

Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done?

a. The patient eats frequent meals in fast-food restaurants.
b. The patient recently traveled to an undeveloped country.
c. The patient had a blood transfusion after surgery in 1998.
d. The patient reports a one-time use of IV drugs 20 years ago.

Answer 18

d. The patient reports a one-time use of IV drugs 20 years ago.

Question 19

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis?

a. Calcium
b. Bilirubin
c. Amylase
d. Potassium

Answer 19

c. Amylase

Question 20

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Abdominal tenderness and guarding
d. Muscle twitching and finger numbness

Answer 20

d. Muscle twitching and finger numbness

Question 21

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase).

a. at bedtime.
b. in the morning.
c. with each meal.
d. for abdominal pain

Answer 21

c. with each meal.

Question 22

A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?

a. Bowel sounds are present.
b. Grey Turner sign resolves.
c. Electrolyte levels are normal.
d. Abdominal pain is decreased.

Answer 22

d. Abdominal pain is decreased.

Question 23

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

a. choose low-fat foods from the menu.
b. perform leg exercises hourly while awake.
c. ambulate the evening of the operative day.
d. turn, cough, and deep breathe every 2 hours.

Answer 23

d. turn, cough, and deep breathe every 2 hours.

Question 24

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

a. Relief of heartburn
b. Cessation of diarrhea
c. Passage of flatus
d. Absence of constipation

Answer 24

a. Relief of heartburn

Question 25

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

a. Bradycardia
b. An increase in neutrophils
c. An increase in RBCs
d. An increase in platelets
e. Localized edema

Answer 25

b. An increase in neutrophils
e. Localized edema

Question 26

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this medication?

a. History of bulimia
b. History of NSAID use
c. Drinks green tea
d. Has a glass of wine with dinner each day

Answer 26

b. History of NSAID use

Question 27

A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about way to manage his condition. Which of the following instructions should the nurse include?

a. Sleep on your left side
b. Drink milk to soothe your stomach
c. Eat four small meals each day
d. Wait to go to bed for 1 hour after eating

Answer 27

d. Wait to go to bed for 1 hour after eating

Question 28

A nurse is caring for a client who has type 1 diabetes mellitus the nurse misread the client’s morning blood glucose level of 210 mg per dL, instead of 120 mg per dL, and administered the wrong dose of insulin and which of the following actions should the nurse identify as a priority.

a. give the client 15 to 20 g of carbohydrates
b. monitor the client for hypoglycemia
c. complete an incident report
d. notify the nurse manager

Answer 28

b. monitor the client for hypoglycemia

Question 29

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?

a. “I am to take my blood sugar reading after meals.”
b. “Insulin allows me to eat ice cream at bedtime.”
c. “A weight reduction program will make me hypoglycemic.”
d. “I give the insulin injections in my abdominal area.”

Answer 29

d. “I give the insulin injections in my abdominal area.”

Question 30

A nurse is providing teaching to an adolescent who has type 1 DM. Which of the following should the nurse include in the teaching?

a. admin glucagon for hyperglycemia
b. obtain an influenza vaccine annually
c. inject insulin in the deltoid muscle
d. take glyburide with breakfast

Answer 30

b. obtain an influenza vaccine annually

Question 31

A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

a. “I will check my urine once a day for ketones.”
b. “I will notify my provider if pre-meal glucose is 120 mg/dL.”
c. “I will check my blood glucose every 4 hours when I am sick.”
d. “I will check blood glucose every 5 minutes when lightheaded.”

Answer 31

c. “I will check my blood glucose every 4 hours when I am sick.”

Question 32

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

A. Respiratory alkalosis
B. Increased anteroposterior diameter of the chest
C. Oxygen saturation level 96%
D. Petechiae on chest

Answer 32

B. Increased anteroposterior diameter of the chest

Question 33

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider?

a. The client has a history of hypertension
b. The client has a history of hypothyroidism
c. The client has a history of bronchial asthma
d. The client has a history of migraine headaches.

Answer 33

c. The client has a history of bronchial asthma

Question 34

A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?

a. Take the medication on an empty stomach to decrease gastrointestinal irritation.
b. Take the medication with orange juice to enhance absorption.
c. Take the medication with milk.
d. Rinse the mouth before taking the iron.

Answer 34

b. Take the medication with orange juice to enhance absorption.

Question 35

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. What action should the nurse plan to take?

Answer 35

Perform neurovascular checks with vital signs.

Question 36

A nurse is assessing a client who is at risk for deep-vein thrombosis (DVT). Which of the following findings is a manifestation of DVT?
a. Pallor in the affected extremity
b. Cramping pain in one foot
c. Auscultation of bruit over pedal pulse
d. Groin/calf tenderness

Answer 36

d. Groin/calf tenderness

Question 38

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

a. A reddened area over the sacrum
b. Stiffness in the lower extremities
c. Difficulty moving the upper extremities
d. Difficulty hearing some types of sounds

Answer 38

a. A reddened area over the sacrum

Question 39

A nurse is caring for a client who has hypoglycemia. The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

a. Decreased BP
b. Fever
c. increased urination
d. Metabolic acidosis

Answer 39

a. Decreased BP

Question 40

A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching?

Answer 40

“I should eat more bananas while taking this medication.”

Question 41

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

a. Place sandbags to maintain right plantar flexion.
b. Position soft pillows against the bottom of the feet.
c. Apply a protective boot to the right ankle.
d. Splint the right lower extremity to maintain proper alignment.

Answer 41

c. Apply a protective boot to the right ankle.

Question 42

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?

a. Triglycerides 130 mg/dl
b. Blood glucose 92 mg/dl
c. LDL 172 mg/dl
d. HDL 84 mg/dl

Answer 42

c. LDL 172 mg/dl

Question 43

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? Select all that apply:

a. The client will list foods that are high in calcium, which should be avoided.
b. The client will walk for 30 min 5 days a week.
c. The client will increase calorie intake by 200 cal per day.
d. The client will replace cigarettes with smokeless tobacco products.
e. The client should be instructed to increase calcium and Vitamin D
f. The client should be instructed to decrease caloric intake

Answer 43

b. The client will walk for 30 min 5 days a week.
e. The client should be instructed to increase calcium and Vitamin D
f. The client should be instructed to decrease caloric intake

Question 44

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse’s priority?

Answer 44

Position the child side-lying.

Question 45

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

a. Weight loss
b. Increased urine output
c. Bradycardia
d. Orthopnea

Answer 45

d. Orthopnea

Question 46

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply)

a. provide privacy
b. ease the client to the floor if standing
c. move furniture away from the client
d. loosen the client’s clothing
e. protect the client’s head with padding
f. restrain the client

Answer 46

a. provide privacy
b. ease the client to the floor if standing
c. move furniture away from the client
d. loosen the client’s clothing
e. protect the client’s head with padding

Question 47

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?

a. Withholding the medication if the heart rate is above 100/min
b. Instructing the client to eat foods that are low in potassium
c. Measuring apical pulse rate for 30 seconds before administration
d. Evaluating the client for nausea, vomiting, and anorexia

Answer 47

d. Evaluating the client for nausea, vomiting, and anorexia

Question 48

A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?

a. ear lobes
b. oral mucosa
c. finger tips
d. eye lids

Answer 48

b. oral mucosa

Question 49

A nurse is caring for 4 hospitalized clients. Which client should the nurse identify at being at risk for fluid volume deficit?

a. The client who has been NPO since midnight for endoscopy
b. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
c. The client who has end-stage renal failure and is scheduled for dialysis today
d. The client who has gastroenteritis and is febrile

Answer 49

d. The client who has gastroenteritis and is febrile

Question 50

A nurse is reinforcing teaching with a client who is scheduled for an ECG. Which of the following instructions should the nurse include?

Answer 50

“You will need to lie still on your left side during this test.”

Question 51

Which information will the nurse include in the asthma teaching plan for a patient being discharged?

a. Use the inhaled corticosteroid when shortness of breath occurs.
b. Inhale slowly and deeply when using the dry powder inhaler (DPI).
c. Hold your breath for 5 seconds after using the bronchodilator inhaler.
d. Tremors are an expected side effect of rapidly acting bronchodilators.

Answer 51

d. Tremors are an expected side effect of rapidly acting bronchodilators.

Question 52

A nurse is caring for a client who has COPD. When developing this client’s plan of care, the nurse should include which of the following interventions?

a. Restrict the client’s fluid intake to less than 2 L/day.
b. Encourage the client to use the upper chest for respiration.
c. Have the client use the early-morning hours for exercise and activity.
d. Instruct the client to use pursed-lip breathing.

Answer 52

d. Instruct the client to use pursed-lip breathing.

Question 53

Which assessment finding in a patient with impaired gas exchange is most useful in evaluating the effectiveness of treatment?

a. Even, unlabored respirations.
b. Pulse oximetry reading of 92%.
c. Absence of wheezes or crackles.
d. Respiratory rate of 18 breaths/min.

Answer 53

b. Pulse oximetry reading of 92%.

Question 54

A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask?

a. “Are you claustrophobic?”
b. “Are you allergic to shellfish?”
c. “Have you taken any bronchodilators today?”
d. “Do you have any metal implants or prostheses?”

Answer 54

c. “Have you taken any bronchodilators today?”

Question 55

Which nursing action for a patient receiving supplemental oxygen could the nurse delegate to experienced assistive personnel (AP)?

a. Measure O2 saturation using pulse oximetry.
b. Monitor for increased O2 need with exercise.
c. Teach the patient about safe use of O2 at home.
d. Adjust O2 to keep saturation in prescribed parameters.

Answer 55

a. Measure O2 saturation using pulse oximetry.

Question 56

What is an adverse effect of isoniazid, rifampin, and pyrazinamide?

Answer 56

Hepatotoxicity

Question 57

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia?

a. shallow respirations
b. hypertensive crisis
c. Diarrhea
d. hyperreflexia

Answer 57

a. shallow respirations

Question 58

A nurse is providing teaching to a pt who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the pt to avoid while taking this medication?

a. Milk
b. Orange juice
c. Coffee
d. Grapefruit juice

Answer 58

d. Grapefruit juice

Question 59

A nurse in a provider’s office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client’s potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

a. Cardiac dysrhythmias
b. Hypoglycemia
c. Seizures
d. Neurogenic shock

Answer 59

a. Cardiac dysrhythmias

Question 60

A nurse is preparing to administer dabigatran to a client who has atrial fib. The nurse should explain that the purpose of this medication is which of the following?

a. To convert atrial fibrillation to sinus rhythm.
b. To dissolve clots in the bloodstream.
c. To slow the response of the ventricles to the fast atrial impulses.
d. To reduce the risk of stroke in clients who have atrial fibrillation.

Answer 60

d. To reduce the risk of stroke in clients who have atrial fibrillation.

Question 61

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. What manifestation should the nurse expect?

a. Gradual onset of several hours
b. Manifestations preceded by a severe headache
c. Maintains consciousness
d. History of neurologic deficits lasting less than 1 hr

Answer 61

b. Manifestations preceded by a severe headache

Question 62

A nurse is teaching a client who is at risk for osteoporosis. Which for the following instructions should the nurse include?

a. Take 400 IU of vitamin D supplement each day.
b. Perform moderate-intensity exercise for 150 min per week.
c. Perform vigorous exercise at least 2 times per week.
d. Take 250 mg of a calcium supplement each day.

Answer 62

b. Perform moderate-intensity exercise for 150 min per week.

Question 63

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet?

a. Carrots
b. Broccoli
c. Cabbage
d. Potatoes

Answer 63

b. Broccoli

Question 64

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis?

a. Aspirin PO
b. Enoxaparin subcutaneous
c. Heparin infusion
d. Warfarin PO

Answer 64

b. Enoxaparin subcutaneous

Question 65

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?

a. Applying cool compresses to her legs
b. Wearing loose, non-constricting stockings
c. Flexing her knees and feet frequently
d. Taking an NSAID tablet daily

Answer 65

c. Flexing her knees and feet frequently

Question 66

While conducting an​ assessment, the nurse concludes that a client is at risk for developing a deep venous thrombosis. Which assessment finding led the nurse to this​ conclusion? (Select all that​ apply.)

a. Taking over-the-corner medication for arthritis
b. A myocardial infarction 2 years ago
c. Controlling type 2 diabetes mellitus diet & exercises
d. Treatment for bladder cancer
e. A history of atrial fibrillation

Answer 66

b. A myocardial infarction 2 years ago
d. Treatment for bladder cancer
e. A history of atrial fibrillation