yurrrrr Flashcards
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
A. Hypophosphatemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypernatremia
B. Hyperkalemia
A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
A. Apply bilateral wrist restraints.
B. Administer opioids for pain.
C. Implement a soft diet.
D. Offer fluids through a straw.
C. Implement a soft diet.
A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?
A. Perform a blind finger sweep.
B. Turn the client to the side.
C. Insert an oral airway.
D. Administer the abdominal thrust maneuver.
D. Administer the abdominal thrust maneuver.
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
A. Exophthalmos
B. Photophobia
C. Lethargy
D. Weight loss
C. Lethargy
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
A. Induce sedation.
B. Suppress respiratory effort.
C. Decrease chest wall compliance.
D. Decrease respiratory secretions.
B. Suppress respiratory effort.
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
A. Decrease the infusion rate on the IV.
B. Document that the client experienced an anaphylactic reaction to the medication.
C. Change the IV infusion site.
D. Apply cold compresses to the neck area.
A. Decrease the infusion rate on the IV.
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
A. Veracity
B. Fidelity
C. Nonmaleficence
D. Autonomy
C. Nonmaleficence
A nurse in a provider’s office is assessing a client who has rheumatoid arthritis (R
A. Low-grade fever
B. Weight loss
C. Anorexia
D. Knuckle deformity
D. Knuckle deformity
A nurse is working with an interdisciplinary disaster committee to develop a community-wide emergency response plan in the event of a nonbiological or chemical incident. The nurse should include which of the following agencies to be notified immediately after calling 911?
A. Office of Emergency Management (OEM)
B. Federal Emergency Management Agency (FEMA)
C. American Red Cross (ARC)
D. U.S. Department of Homeland Security (DHS)
A. Office of Emergency Management (OEM)
A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?
A. The health care proxy does not go into effect until I am incapable of making decisions.
B. I have to choose a family member as my health proxy.
C. I can change who I designate as my health care proxy at any time.
D. If I become incapacitated, end-of-life choices will be made by my proxy.
B. I have to choose a family member as my health proxy.
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
A. A client who has a small circular partial-thickness burn of the left calf.
B. A client who has severe respiratory stridor and a deviated trachea.
C. A client who has a splinted open fracture of the left medial malleolus.
D. A client who has a massive head injury and is experiencing seizures.
B. A client who has severe respiratory stridor and a deviated trachea.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
A. Generalized urticaria.
B. Distended jugular veins.
C. Blood pressure 184/92 mm Hg.
D. Bilateral flank pain.
A. Generalized urticaria.
A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
A. A high concentration of carbon monoxide can cause death.
B. I should purchase a carbon monoxide detector for my home.
C. Breathing in carbon monoxide can cause headaches and nausea.
D. I can detect the presence of carbon monoxide by a metallic odor.
D. I can detect the presence of carbon monoxide by a metallic odor.
A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
A. I’ll be sure to eat more foods with vitamin K.
B. I’ll take aspirin for my headaches.
C. I’ll use my electric razor for shaving.
D. It’s okay to have a couple of glasses of wine with dinner each evening.
C. I’ll use my electric razor for shaving.
A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include?
A. You can expect swelling of the ankles while taking this medication.
B. Do not take this medication on an empty stomach.
C. Limit your fluid intake to meal times.
D. Increase your daily intake of dietary fiber.
D. Increase your daily intake of dietary fiber.
A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
A. Administer the medications 5 minutes apart.
B. Hold pressure on the conjunctival sac for 2 minutes following application of drops.
C. It is not necessary to remove contact lenses before administering medications.
D. Administer the medications by touching the tip of the dropper to the sclera of the eye.
A. Administer the medications 5 minutes apart.
A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
A. Use wool blankets on your bed.
B. Do not adjust the oxygen flow rate.
C. Store unused oxygen tanks horizontally.
D. Check your oxygen equipment once each week.
B. Do not adjust the oxygen flow rate.
A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?
A. Ulnar deviation
B. Symmetric joints affected
C. Pain worsens with activity
D. Weight loss
C. Pain worsens with activity
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
A. Relapse is an indication that you are not taking your medications properly.
B. You should keep your provider’s and therapist’s number with you.
C. Taking an additional dose of medication is appropriate as soon as signs of relapse appear.
D. You should be aware that excessive sleeping is an early sign of relapse.
B. You should keep your provider’s and therapist’s number with you.
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
A. Take the medication with orange juice.
B. Take the medication between meals.
C. Take the medication on an empty stomach.
D. Take the medication with milk.
D. Take the medication with milk.
A public health nurse is teaching a group of nurses about smallpox. Which of the following statements by one of the nurses indicates understanding of the teaching?
A. Unlike chickenpox, the vesicles of smallpox are more abundant on the face.
B. Smallpox lesions appear in various stages of healing.
C. Vaccination against smallpox provides lifelong immunity.
D. There are rare, occasional occurrences of smallpox.
A. Unlike chickenpox, the vesicles of smallpox are more abundant on the face.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
A. A negative-pressure isolation room.
B. A private room.
C. A semi-private room with a client who has pediculosis capitis.
D. A positive-pressure isolation room.
B. A private room.
A nurse at a provider’s office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply)
A. Add cream to soups.
B. Dip meats in eggs and bread crumbs before cooking.
C. Use milk instead of water in recipes.
D. Top fruits with yogurt.
E. Increase fluids during meals.
A. Add cream to soups.
B. Dip meats in eggs and bread crumbs before cooking.
C. Use milk instead of water in recipes.
D. Top fruits with yogurt.
A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
A. Intense pruritus
B. Irregular borders
C. Uniform pigmentation
D. Purulent drainage
B. Irregular borders
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
A. Creatinine
B. Aspartate aminotransferase (AST)
C. Amylase
D. Antidiuretic hormone (ADH)
B. Aspartate aminotransferase (AST)
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
A. Handrails are present in the bathroom.
B. Electrical cords are placed along the walls.
C. Uses a microwave for cooking.
D. Scatter rugs are present in the kitchen.
D. Scatter rugs are present in the kitchen.
A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
A. An infant who has pertussis and is receiving oxygen via nasal cannula.
B. A school-age child who has diabetes mellitus and requires blood glucose monitoring.
C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
D. A toddler who has both arms in casts and needs to be fed his breakfast.
A. An infant who has pertussis and is receiving oxygen via nasal cannula.
A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide?
A. Stop taking the pills and switch to a different contraceptive method.
B. Take a home pregnancy test.
C. Do not have vaginal intercourse until after your next period.
D. Take the missed dose now, then continue the medication as ordered.
D. Take the missed dose now, then continue the medication as ordered.
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
A. Check the drainage for glucose.
B. Notify the client’s provider.
C. Document the amount of drainage.
D. Obtain a culture of the drainage.
A. Check the drainage for glucose.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
A. Bradycardia
B. Hyperglycemia
C. Dehydration
D. Polyphagia
C. Dehydration
A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility?
A. Health care provider
B. Hospital pharmacist
C. Nurse manager
D. Medication sales representative
B. Hospital pharmacist
A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
A. Place a black tag on the client’s upper body and attempt to help the next client in need.
B. Reposition the client’s upper airway a second time before assessing his respirations.
C. Start CPR.
D. Place a red tag on the client’s upper body and obtain immediate help from other personnel.
A. Place a black tag on the client’s upper body and attempt to help the next client in need.
A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
A. Chicken broth
B. Flavored gelatin
C. Cranberry juice
D. Skim milk
D. Skim milk
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
A. Using the palm of the hand, feel for lumps using a circular motion.
B. Expect some breast dimpling or discharge with age.
C. Breasts can be examined in the shower with soapy hands.
D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
C. Breasts can be examined in the shower with soapy hands.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
A. Blurred vision
B. Severe headache
C. Oriented to person, place, and year
D. Bradycardia
B. Severe headache
A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?
A. Supported Sims
B. Semi-Fowler’s
C. Dorsal recumbent
D. Prone
B. Semi-Fowler’s
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
A. Turn the client every 4 hours.
B. Brush the client’s teeth with a suction toothbrush every 12 hours.
C. Provide humidity by maintaining moisture within the ventilator tubing.
D. Position the head of the client’s bed in the flat position.
B. Brush the client’s teeth with a suction toothbrush every 12 hours.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
A. Pruritus
B. Swollen gums
C. Dysphagia
D. Urinary hesitancy
C. Dysphagia
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
A. 0730
B. 0745
C. 0815
D. 0720
A. 0730
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
A: Inspect the abdomen for skin integrity.
B: Ask the client about having a history of abdominal pain.
C: Auscultate the abdomen for bowel sounds.
D: Percuss the abdomen in each of the four quadrants.
E: Palpate the abdomen gently for tenderness.
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A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
A. Assist the client to sit upright in a chair for 4 hours at a time.
B. Expect clear drainage on the spinal dressing.
C. Log roll the client every 2 hours.
D. Perform neurological checks every 8 hours.
C. Log roll the client every 2 hours.
A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client?
A. Draw sheet
B. Log roll
C. Sliding board
D. Hoyer lift
B. Log roll
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
A. WBC count
B. BUN
C. Potassium
A. WBC count
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison’s disease. Which of the following findings should the nurse expect?
A. Purple striations
B. Hirsutism
C. Hyperpigmentation
D. Intention tremors
C. Hyperpigmentation
A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
A. Don sterile gloves.
B. Position the client supine with knees bent.
C. Use a rectal applicator for insertion.
D. Insert the suppository just beyond the internal sphincter.
E. Lubricate the index finger.
D. Insert the suppository just beyond the internal sphincter.
E. Lubricate the index finger.
A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?
A. Reduced chest width
B. Increased force of isometric contraction
C. Decreased muscle mass
D. Thickened vertebral discs
C. Decreased muscle mass
A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?
A. Administer 50,000 units of heparin by IV bolus every 12 hours.
B. Have vitamin K available on the nursing unit.
C. Use tubing specific for heparin sodium when administering the infusion.
D. Check the activated partial thromboplastin time (aPTT) every 6 hours.
D. Check the activated partial thromboplastin time (aPTT) every 6 hours.
A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
A. Place a pillow under the client’s head.
B. Insert a padded tongue blade into the client’s mouth.
C. Apply a face mask for oxygen administration.
D. Gently restrain the client’s extremities.
A. Place a pillow under the client’s head.
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
A. A client who has Guillain-Barré syndrome
B. A client who has systemic sclerosis
C. A client who has amyotrophic lateral sclerosis (ALS)
D. A client who has a lumbosacral spinal tumor
D. A client who has a lumbosacral spinal tumor
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
A. Akathisia
B. Tardive dyskinesia
C. Dystonia
B. Tardive dyskinesia
A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?
A. Perform the Heimlich maneuver.
B. Slap the client on the back several times.
C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
D. Observe the client before taking further action.
A. Perform the Heimlich maneuver.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
A. Distorted perceptual field.
B. Urinary frequency.
C. Rapid speech.
C. Rapid speech.
A nurse is caring for a client who is postpartum and asks the nurse when her breast milk will “come in.” Which of the following responses should the nurse make?
A. Within 2 days.
B. In 3 to 5 days.
C. In about 10 days.
D. In 6 to 8 days.
B. In 3 to 5 days.
A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?
A. I will wipe from the back to front with the cleaning cloth.
B. I need to urinate a small amount in the toilet before collecting the sample.
C. I should let the urine cool to room temperature before sending it to the lab.
D. I should not collect a urine sample when I am menstruating.
B. I need to urinate a small amount in the toilet before collecting the sample.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
A. The medication will reduce inflammation.
B. The medication will decrease coughing episodes.
C. The medication will prevent wheezing.
D. The medication will open the airway.
E. The medication will stimulate the flow of mucus.
C. The medication will prevent wheezing.
D. The medication will open the airway.
A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
A. The ethics committee will need to approve this request for you.
B. I will ask the nursing supervisor to obtain the medical records for you.
C. The healthcare provider will share this information with you.
D. The client must provide permission to share the records with you.
D. The client must provide permission to share the records with you.
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
A. This stage is when testing occurs to identify boundaries of interpersonal behaviors.
B. Consensus evolves in this stage.
C. This stage involves constructive efforts on the part of the group members.
D. Resistance is evident as subgroups form in this stage.
B. Consensus evolves in this stage.
A nurse is educating community members about how to prepare for a disaster. Which of the following items should be included in a disaster preparedness kit? (Select all that apply)
A. Clean clothing.
B. Personal identification.
C. Three quarts of water per person.
D. Matches.
E. Prescription medications.
A. Clean clothing.
B. Personal identification.
D. Matches.
E. Prescription medications.
A nurse is caring for four clients who have drainage tubes. Which of the following clients is at risk for hypokalemia?
A. The client who has a tracheostomy tube attached to humidified oxygen.
B. The client who has an indwelling urinary catheter to gravity drainage.
C. The client who has a chest tube to water seal.
D. The client who has a nasogastric tube to suction.
D. The client who has a nasogastric tube to suction.
A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?
A. Remove all objects that contain latex from the client’s room.
B. Verify the client’s medication prescriptions do not include cephalosporin.
C. Notify dietary services to adjust the client’s diet.
D. Have the client purchase a medication alert bracelet to wear in the hospital.
B. Verify the client’s medication prescriptions do not include cephalosporin.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have a natural childbirth. Which of the following responses should the nurse make?
A. Maybe next time you can have a vaginal delivery.
B. It sounds like you are feeling sad that things didn’t go as planned.
C. At least you know you have a healthy baby.
D. You can resume sensations sooner than if you had delivered vaginally.
B. It sounds like you are feeling sad that things didn’t go as planned.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
A. Your largest meal of the day should be in the evening.
B. Eating yogurt can help decrease the amount of gas that I have.
C. Carbonated beverages can help control odor.
D. I should eliminate pasta from my diet so that I don’t have many loose stools.
B. Eating yogurt can help decrease the amount of gas that I have.
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
A. Family history of cardiac disease.
B. Increasing age.
C. Diagnosis of diabetes mellitus.
D. Cigarette smoking.
D. Cigarette smoking.
A nurse is caring for a client who has delusional behavior and states, “I can’t go to group therapy today. I am expecting a high-level official to visit me.” The nurse responds, “I understand, but it is time for group therapy and we expect everyone to attend. Let’s walk over together.” For which of the following reasons is the nurse’s response considered therapeutic?
A. It clearly articulates the expectations of the client.
B. It demonstrates empathy towards the client.
C. It sets limits on the client’s manipulative behavior.
D. It uses reflection when talking with the client.
B. It demonstrates empathy towards the client.
A nurse is assessing a client who is receiving metoprolol. Which of the following indicates a therapeutic effect?
A. Decreased blood pressure.
B. Decreased dysrhythmias.
C. Increased urine output.
D. Decreased pulse.
A. Decreased blood pressure.
A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
A. Verify the provider’s prescription to discontinue the tube.
B. Disconnect the tube from the wall suction.
C. Perform hand hygiene.
D. Provide mouth care to the client.
A. Verify the provider’s prescription to discontinue the tube.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
A. Obtain a 12-lead ECG.
B. Suggest that the client use a salt substitute.
C. Ask the client to add citrus juices and bananas to her diet.
D. Obtain a blood sample for a serum sodium level.
A. Obtain a 12-lead ECG.
A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
A. Restrict the client’s oral fluid intake.
B. Remind the client he might feel a constant urge to void.
C. Weigh the client every evening.
D. Monitor the client’s urine output every 6 hours.
B. Remind the client he might feel a constant urge to void.
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?
A. Insert a nasogastric tube.
B. Administer an antiemetic.
C. Auscultate bowel sounds.
D. Encourage the client to ambulate.
B. Administer an antiemetic.
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
A. Promote oral hygiene.
B. Ensure adequate nutrition.
C. Prevent aspiration.
D. Relieve the client’s pain.
C. Prevent aspiration.
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. Absence of Rovsing’s sign.
C. Low-grade fever.
D. Rigid abdomen.
A. Sudden decrease in abdominal pain.
A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?
A. Constipation
B. Sensitivity to cold
C. Weight gain of 4.5 kg (10 lbs) in 3 weeks
D. Frequent mood changes
D. Frequent mood changes
A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
A. Vesicles on the skin
B. Respiratory failure
C. Flu-like symptoms
D. Coughing of blood
B. Respiratory failure
A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?
A. Explaining the procedure, risks, and benefits
B. Reviewing preoperative instructions
C. Obtaining test results
D. Ensuring that a signed surgical consent form was completed
E. Assessing the current health status of the client
A. Explaining the procedure, risks, and benefits
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
A. Plan a plan of care for a client when postoperative from an appendectomy
B. Provide discharge instructions to a confused client’s spouse
C. Administer a tap-water enema to a client who is preoperative
D. Clean vital signs from a client who is 6 hours postoperative
E. Catheterize a client who has not voided in 8 hours
C. Administer a tap-water enema to a client who is preoperative
E. Catheterize a client who has not voided in 8 hours
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
A. Flu-like symptoms and night sweats
B. Fungal and bacterial infections
C. Pneumocystis lung infection
D. Kaposi’s sarcoma
A. Flu-like symptoms and night sweats
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
A. Dependent rubor
B. Thick, deformed toenails
C. Hair loss
D. Edema
D. Edema
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
A. Wrap the stump with an elastic bandage in a figure-eight configuration.
B. Remove the elastic bandage and re-wrap the stump once per day.
C. Perform passive range of motion exercises once daily.
D. Secure the elastic bandage to the lowest joint.
A. Wrap the stump with an elastic bandage in a figure-eight configuration.
A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
A. Plan of care changes for the upcoming shift
B. Intracranial pressure readings
C. Glasgow results
D. Code status
D. Code status
A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?
A. Airborne
B. Contact
C. Protective
D. Droplet
D. Droplet
A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?
A. Tamoxifen
B. Leuprolide
C. Finasteride
D. Cyclophosphamide
B. Leuprolide
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
A. Dried fruits
B. Dried peas
C. Eggs
D. Pasta
C. Eggs
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
A. Obtain a 12-lead ECG.
B. Suggest that the client use a salt substitute.
C. Advise the client to add citrus juices and bananas to her diet.
D. Obtain a blood sample for a serum sodium level.
A. Obtain a 12-lead ECG.
A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the medication is treatment for exposure to which of the following agents?
A. Smallpox
B. Anthrax
C. Ebola virus
D. Sarin gas
B. Anthrax
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
A. Tell the client to expect dark stools following chemotherapy.
B. Have the client swish with commercial mouthwash before therapy.
C. Administer an antiemetic prior to the procedure.
D. Have the client floss 4 times daily.
C. Administer an antiemetic prior to the procedure.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
A. Painful urination
B. Urge incontinence
C. Critically elevated prostate-specific antigen (PSA) level
D. Difficulty starting the flow of urine
D. Difficulty starting the flow of urine
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
A. Hemorrhage
B. Infection
C. Urinary retention
D. Pain
A. Hemorrhage
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
A. Decreased fat in stools
B. Decreased watery stools
C. Decreased mucus in stools
D. Decreased black tarry stools
A. Decreased fat in stools
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
A. Leave the pad in place for at least 40 minutes
B. Set the pad’s temperature to 42.2°C (108°F)
C. Use safety pins to keep the pad in place
D. Stop the treatment if the client’s skin becomes red
D. Stop the treatment if the client’s skin becomes red
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
A. Take naproxen for generalized discomfort
B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
C. Take diuretics early in the morning and before bedtime
D. Exercise at least three times per week
B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
A school nurse is caring for a school-age child who has asthma.
Exhibits
Click to highlight the intervention the nurse should take. To deselect a finding, click on the finding again.
Reported to the nurse’s office with complaints of nausea and a slight cough. The client rested and then returned to the classroom.
1300:
Following lunch, the client was playing soccer on the playground. Reported to the nurse’s office with complaints of cough and shortness of breath. Slight wheezing noted in the bases of the lungs.
A. Administer acetaminophen
B. Have the child wear a mask
C. Administer a dose of montelukast
D. Encourage oral fluids
E. Administer albuterol nebulizer
F. Evaluate the child’s peak flow
G. Initiate chest percussions
H. Have the child sit upright in a position of comfort
A. Administer acetaminophen
E. Administer albuterol nebulizer
A nurse is caring for a client who is 2 hours postoperative after having a total abdominal hysterectomy.
Exhibits
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
dropdown
,
dropdown
and
dropdown
The client is at risk for developing
Pneumonia,
Deep vein thrombosis, and
Pressure ulcers
A nurse is caring for a patient on a medical-surgical unit.
Exhibits
A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply
A. WBC Count
B. Parkinson’s disease
C. Potassium level on day 2
D. Furosemide
E. Low blood pressure
B. Parkinson’s disease
C. Potassium level on day 2
D. Furosemide
E. Low blood pressure
A nurse is caring for a 73-year-old client in the emergency department (ED).
Exhibits
It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications:
A. Type and match for 2 units of packed RBCs
B. Rapidly administer 30 mL/kg of normal saline
C. Measure lactate level
D. Obtain blood cultures
E. Obtain a wound culture
B. Rapidly administer 30 mL/kg of normal saline
C. Measure lactate level
D. Obtain blood cultures
E. Obtain a wound culture
A nurse is caring for a client in the emergency department (ED).
Exhibits
The nurse is providing the client education prescribed by the provider. Which of the following instructions should the nurse include in the education? (Select all that apply)
Day 1: Client presents to ED with complaint of ‘not feeling well.’ Client appears restless, states abdomen is cramping and has had severe nausea for the past several hours. The client has had 1 loose stool in the past 1 hour. Skin is dry and intact with good turgor. Bowel sounds hyperactive in all 4 quadrants. The client attended a work picnic yesterday and multiple coworkers have similar symptoms.
Day 2: Client returns to ED with worsening symptoms. Client reports worsening nausea and persistent loose stools. Skin dry and tenting. Abdomen soft and tender, bowel sounds hyperactive in all 4 quadrants.
A. Wash raw carrots before cooking.
B. Separate raw foods from ready-to-eat foods.
C. Wash utensils with warm water.
D. Practice good hand washing after handling raw eggs, meat, or poultry.
E. Ensure all food is cooked to 165°F. Promptly refrigerate foods when finished eating.
B. Separate raw foods from ready-to-eat foods.
D. Practice good hand washing after handling raw eggs, meat, or poultry.
E. Ensure all food is cooked to 165°F. Promptly refrigerate foods when finished eating.
A nurse is caring for an oldest patient.
Exhibits
For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Guardians brought the client to the emergency department (ED) for pain in the left arm that began last evening. The client has a history of sickle cell disease diagnosed at age 4. The client has a prescription for oral morphine sulfate and took one dose last evening at 1800 and this morning at 0900. The client reports no relief from pain, reporting it as 9 on a scale of 0 to 10.
Options Anticipated Contraindicated
A . Ice packs to affected area 15 minutes on, 15 minutes off
B . Intravenous fluids (IVF) at maintenance rate
C . Ketorolac IV for pain
D . Ambulate in hallway with supervision
E . Meperidine IV for pain
anticipated:
B . Intravenous fluids (IVF) at maintenance rate
C . Ketorolac IV for pain
contraindicated:
A . Ice packs to affected area 15 minutes on, 15 minutes off
D . Ambulate in hallway with supervision
E . Meperidine IV for pain
A nurse is caring for a client during a routine prenatal visit.
Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
actions to take:
- administer iron
- teach client about diet rich in iron
condition:
- iron deficiency anemia
parameteres:
- hemoglobin levels
- hematocrit levels
A nurse is caring for a client who is 1 day postoperative following a right-sided thoracotomy with a chest tube insertion.
Exhibits
A nurse prioritizes care after completing the assessment and initiates the following action.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
actions to take:
- administer oxygen as prescribed
- ensure chest tube is functioning properly
condition:
- pneumothorax
parameteres:
- respiratory rate and effort
- oxygen saturation levels
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, “I don’t know what I will do if they find I have cancer.” Which of the following responses should the nurse make?
A. Why do you think you might have cancer when your diagnosis is a benign condition?
B. I’m looking at your chart here and I don’t see any reason for you to worry about that.
C. I’m hearing that you are concerned that it might turn out that you have cancer.
D. I think that’s something you need to discuss with your provider.
C. I’m hearing that you are concerned that it might turn out that you have cancer.
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?
A. I should take aspirin for minor aches and pains while taking this medication.
B. I can expect a sore throat for the first week after starting this medication.
C. I should take my flu vaccine within one week of starting this medication.
D. I should eat more bananas while taking this medication.
D. I should eat more bananas while taking this medication.
A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply)
A. Lisinopril
B. Clopidogrel
C. Atorvastatin
D. Furosemide
E. Doxazosin
A. Lisinopril
D. Furosemide
E. Doxazosin
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
A. It is a good idea to use the handrails in the bathroom.
B. I should get a longer cord for my telephone.
C. I should place a throw rug over electrical cords.
D. I should use chairs without armrests.
A. It is a good idea to use the handrails in the bathroom.
A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?
A. I should eat a snack half an hour before playing soccer.
B. My morning blood glucose should be between 90 and 130.
C. I should not take my regular insulin when I am sick.
D. I can store unopened bottles of insulin in the freezer.
A. I should eat a snack half an hour before playing soccer.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?
A. Aspirate for a blood return before depressing the plunger.
B. Insert the needle at a 45-degree angle.
C. The nurse should not expel the air bubble in the prefilled syringe.
D. Administer the medication 2.54 cm (1 inch) from the umbilicus.
C. The nurse should not expel the air bubble in the prefilled syringe.
A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
A. Transporting a school-age client who is in traction to another department.
B. Reading a book to a preschool client who has AIDS.
C. Playing a computer video game with an adolescent who has sickle cell disease.
D. Rocking an infant who was admitted for croup.
A. Transporting a school-age client who is in traction to another department.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives?
A. 0.9% sodium chloride
B. Dextrose 5% in water
C. Dextrose 10% in water
D. Lactated Ringer’s solution
C. Dextrose 10% in water
A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding the prevention of postoperative complications should the nurse include in the teaching?
A. Discuss the visitation policy.
B. Instruct the client about the use of a sequential compression device.
C. Teach the client how to use the PCA pump.
D. Review the pain scale.
B. Instruct the client about the use of a sequential compression device.
A charge nurse is discussing the phases of community response to disaster with nursing staff. Which of the following statements indicates an understanding of the heroic phase of disaster response?
A. Normalcy begins to return to the community.
B. Personnel are willing to work in dangerous conditions to provide assistance.
C. Responders experience exhaustion due to extended relief efforts.
D. Survivors come together and share stories of survival.
B. Personnel are willing to work in dangerous conditions to provide assistance.
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?
A. Increased urinary output
B. Hyperactive bowel sounds
C. Bradycardia
D. Nausea and vomiting
D. Nausea and vomiting
A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse about what the provider might be planning to do. Which of the following nursing responses should the nurse make?
A. Provide the client with articles from the internet that explain colon cancer stages.
B. Encourage the client to write down questions to ask the provider.
C. Explain the various options available for treatment based on the cancer stage.
D. Assure the client that the provider will explain what has been planned.
B. Encourage the client to write down questions to ask the provider.
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?
A. Place the shoulder harness straps below the level of the newborn’s armpits.
B. Keep the car seat rear-facing until the newborn can sit unsupported.
C. Place the retainer clip across the newborn’s abdomen.
D. Position the newborn at a 45-degree angle in the car seat.
D. Position the newborn at a 45-degree angle in the car seat.
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (G85). Which of the following questions should the nurse ask the client?
A. Have you had a recent influenza infection?
B. Have you traveled overseas recently?
C. Do you have a history of chronic alcohol abuse?
D. Are you taking a multivitamin?
A. Have you had a recent influenza infection?
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?
A. Sometimes my child acts bossy with his friends.
B. The teacher says my child has to squint to see the board.
C. My child has recently lost both front top teeth.
D. My child often cheats when we play board games.
B. The teacher says my child has to squint to see the board.
A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? (Select all that apply)
A. Using a kitchen spoon to administer the medication.
B. Written information about the medication.
C. The reason why the child is taking the medication.
D. The adverse effects of the medication.
E. Stopping the medication when the child feels better.
B. Written information about the medication.
C. The reason why the child is taking the medication.
D. The adverse effects of the medication.
An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?
A. A client who had a stroke and is to be admitted.
B. A client who is one-day postoperative following a total abdominal hysterectomy.
C. A client who has acute pancreatitis.
D. A client who has terminal end-stage renal disease.
B. A client who is one-day postoperative following a total abdominal hysterectomy.
A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?
A. Dilated scalp veins
B. Overriding suture lines
C. Hypertension
D. A backward sloping appearance of the forehead
A. Dilated scalp veins
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client’s history?
A. Hyperlipidemia
B. Gallstones
C. COPD
D. Diabetes mellitus
B. Gallstones
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
A. Pulmonary edema
B. An upper respiratory infection
C. Atelectasis
D. Delayed gastric emptying
C. Atelectasis
A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?
A. Hypothermia
B. Localized edema
C. Numbness of toes on the affected foot
D. Bradycardia
B. Localized edema
A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching?
A. I can wear heels up to 2 inches in height.
B. I should sleep lying flat with my legs extended straight.
C. I should keep my weight within 10 percent of my ideal weight.
D. I should increase high potassium foods in my diet.
C. I should keep my weight within 10 percent of my ideal weight.
A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?
A. Administer a test dose first.
B. Infuse the medication with an IV pump.
C. Cover the IV container with dark paper.
D. Infuse the medication at 35 mg/min.
B. Infuse the medication with an IV pump.
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
A. A private room in a quiet location on the unit.
B. A private room across from the exercise room.
C. A semi-private room across from the day room.
D. A semi-private room across from the snack area.
A. A private room in a quiet location on the unit.
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?
A. Diuretic use
B. BMI less than 25
C. Hypocalcemia
D. Family history
D. Family history
A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
A. Client reports knee pain changed from 4/10 to 6/10.
B. Pulse oximetry changed from 98% to 96%.
C. Temperature changed from 37.2°C (99.0°F) to 37.5°C (99.5°F).
D. Systolic blood pressure changed from 140 mm Hg to 110 mm Hg.
D. Systolic blood pressure changed from 140 mm Hg to 110 mm Hg.
A nurse is preparing to administer phenytoin 50 mg IV bolus to a client who has a seizure disorder. The medication is supplied as a 50 mg/mL vial. Which of the following actions should the nurse take?
A. Administer the medication over 1 minute.
B. Dilute the medication with sterile water before injecting.
C. Slow the injection if the medication crystallizes.
D. Follow the injection with sterile water.
A. Administer the medication over 1 minute.
A nurse is caring for a 10-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
A. You sound overwhelmed. Let’s talk about this some more.
B. I agree. His well-being is the most important.
C. Tell me more about how you are feeling about your son’s activities.
D. You might want to use tutors to home-school him.
C. Tell me more about how you are feeling about your son’s activities.
A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse’s job description. Which of the following is an appropriate nursing response?
A. I would be happy to do whatever I can to help you.
B. What I think you should do is wait for the days when you feel better and do your grocery shopping then.
C. I won’t be able to shop for you today because I have to get home to my family.
D. Let’s look at some other resources to solve this problem.
D. Let’s look at some other resources to solve this problem.
A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?
A. Free T4
B. Thyroid-stimulating hormone (TSH)
C. Serum T3
D. Serum T4
B. Thyroid-stimulating hormone (TSH)
A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include?
A. Your baby will receive the first diphtheria, tetanus, pertussis vaccine at the 2-week well-baby visit.
B. Your baby should receive the measles, mumps, rubella vaccine at 6 months.
C. Your baby will only receive the hepatitis B vaccine prior to discharge.
D. Your baby should receive the pneumococcal conjugate vaccine on his first birthday.
C. Your baby will only receive the hepatitis B vaccine prior to discharge.
A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?
A. Drive the client to the nearest emergency department.
B. Call emergency services.
C. Find a location for the client to sit.
D. Obtain the telephone number of the client’s provider.
B. Call emergency services.
A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?
A. Weigh the client daily.
B. Monitor the client for signs of bleeding.
C. Monitor the client’s respirations every 4 hours.
D. Administer an antacid with the medication to decrease nausea.
A. Weigh the client daily.
A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following statements indicates an understanding of the teaching?
A. I may have a dry mouth while taking this medication.
B. This medication may cause me to urinate frequently.
C. This medication will help me stop smoking.
D. I should expect flu-like symptoms while taking this medication.
A. I may have a dry mouth while taking this medication.
A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
A. Withhold oral fluids and food.
B. Auscultate the client’s lungs.
C. Provide oral hygiene.
D. Assist the client to a side-lying position.
A. Withhold oral fluids and food.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
A. Cardiac glycosides
B. Thyroid hormones
C. Anticoagulants
D. NSAIDs
B. Thyroid hormones
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
A. Ask the client to blow his nose.
B. Suction the nostril.
C. Notify the physician.
D. Test the drainage for glucose.
D. Test the drainage for glucose.
A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply)
A. The preschooler mispronounces words.
B. The preschooler speaks in three-word sentences.
C. The preschooler stutters when speaking.
D. The preschooler talks to himself when reading.
E. The preschooler speaks in a nasally tone.
A. The preschooler mispronounces words.
B. The preschooler speaks in three-word sentences.
C. The preschooler stutters when speaking.
E. The preschooler speaks in a nasally tone.
A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include?
A. Raw celery
B. Grapes
C. Peanut butter
D. Sliced bananas
D. Sliced bananas
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?
A. Babinski’s sign
B. Chvostek’s sign
C. Brudzinski’s sign
D. Kernig’s sign
B. Chvostek’s sign
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
A. Adopt a neutral attitude when providing care.
B. Wait for the client to initiate interaction.
C. Disclose some personal information to the client to demonstrate approachability.
D. Approach the client frequently throughout the day for brief interactions
A. Adopt a neutral attitude when providing care.
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?
A. Low-protein, low-potassium diet
B. Regular diet, no added salt
C. Low-carbohydrate, low-protein diet
D. Low-sodium, fluid-restricted diet
D. Low-sodium, fluid-restricted diet
A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Sees himself as inferior to others.
B. Persistently holds grudges.
C. Demonstrates a grandiose sense of self-importance.
D. Desires to be the center of attention.
E. Believes that others are deceiving him.
B. Persistently holds grudges.
E. Believes that others are deceiving him.
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
A. Implement a resolution.
B. Evaluate the results.
C. Brainstorm solutions.
D. Identify the problem.
D. Identify the problem.
A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.
A. Apply intermittent ice to the affected ankle for the first 48 hours.
B. Wrap the affected ankle with an elasticized compression bandage.
C. Apply full weight-bearing on the affected ankle.
D. Elevate the affected ankle above the level of the heart.
E. Apply a heating pad intermittently to the affected ankle after 48 hours.
A. Apply intermittent ice to the affected ankle for the first 48 hours.
B. Wrap the affected ankle with an elasticized compression bandage.
D. Elevate the affected ankle above the level of the heart.
E. Apply a heating pad intermittently to the affected ankle after 48 hours.
A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?
A. Testing new nurses for exposure to tuberculosis.
B. Providing treatment for clients who have chronic obstructive pulmonary disease.
C. Performing screening for sexually transmitted infections.
D. Administering influenza immunizations at a local health fair
B. Providing treatment for clients who have chronic obstructive pulmonary disease.
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority?
A. Temperature 38.2°C (100°F)
B. The client reports weakness of the lower extremities.
C. The client reports some itching.
D. Blood pressure 80/56 mm Hg
D. Blood pressure 80/56 mm Hg
A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of an acute hemolytic reaction?
A. A productive cough
B. Distended neck veins
C. Client report of low back pain
D. Client report of tinnitus
C. Client report of low back pain
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
A. Reinforce discharge teaching to clients.
B. Instruct the assistive personnel (AP) to focus on clients’ ADLs.
C. Stock additional unit supplies.
D. Focus on providing care that prevents life-threatening emergencies.
D. Focus on providing care that prevents life-threatening emergencies.
A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply)
A. Apply restraints if the client becomes agitated.
B. Administer pantoprazole as prescribed.
C. Verify the prescribed ventilator settings daily.
D. Elevate the head of the bed to at least 30 degrees.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.
B. Administer pantoprazole as prescribed.
C. Verify the prescribed ventilator settings daily.
D. Elevate the head of the bed to at least 30 degrees.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.
A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate?
A. 90 bpm
B. 100 bpm
C. 110 bpm
D. 120 bpm
A. 90 bpm
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?
A. Aplastic anemia results in an increased rate of RBC destruction.
B. Aplastic anemia is associated with a decreased intake of iron.
C. Aplastic anemia results from decreased bone marrow production of RBCs.
D. Aplastic anemia results in an inability to absorb vitamin B12.
A. Aplastic anemia results in an increased rate of RBC destruction.
A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?
A. The procedure will be cancelled if the urinalysis indicates the presence of red blood cells.
B. You will be able to resume your regular diet as soon as the test is complete.
C. High-frequency sound waves will be used to identify renal system structures.
D. After the procedure, you will be encouraged to drink plenty of fluids.
D. After the procedure, you will be encouraged to drink plenty of fluids.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
A. Heart rate
B. Blood pressure
C. Urine output
D. Weight
A. Heart rate
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
A. Consume a high-protein diet.
B. You may donate blood 6 months after completing the medication regimen.
C. Take acetaminophen every 4 hours, as needed, for discomfort.
D. Rest frequently throughout the day.
D. Rest frequently throughout the day.
A nurse observes a parent administer a prescribed oral medication to an infant. Which of the following statements indicates a need for further instruction?
A. Administers medication with an oral syringe.
B. Inserts the medication in the infant’s buccal cavity.
C. Allows the infant to swallow some of the medication before administering more.
D. Positions the infant in a supine position.
D. Positions the infant in a supine position.
A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?
A. Activate the patch 30 minutes after application.
B. Take this medication daily to prevent headaches.
C. Use contraception while taking this medication.
D. You can bathe with the patch in place.
C. Use contraception while taking this medication.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
A. Fetal position is persistent occiput posterior.
B. Maternal pelvis is gynecoid.
C. Fetal attitude is in general flexion.
D. Fetal lie is longitudinal.
A. Fetal position is persistent occiput posterior.
A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?
A. Perform a rapid head-to-toe assessment.
B. Place a red tag on the client’s upper body.
C. Have the client’s wife drive him to the hospital.
D. Place a yellow tag on the client’s upper body.
B. Place a red tag on the client’s upper body.
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates concrete thinking?
A. I am a prophet of the most high king.
B. The voices tell me that I must avoid large crowds.
C. I am sure that each problem has only one solution.
D. I know that you and the other nurses are trying to poison me.
C. I am sure that each problem has only one solution.
A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron?
A. Tea
B. Dried beans
C. Milk
D. Tomato juice
D. Tomato juice
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client’s neurovascular status?
A. Monitor the client’s calf for edema.
B. Palpate the femoral pulse.
C. Measure the circumference of the thigh.
D. Instruct the client to wiggle his toes.
B. Palpate the femoral pulse.
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?
A. Bright yellow
B. Bright red
C. Dark amber
D. Pale pink
D. Pale pink
A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?
A. Oxygen saturation 95%
B. Respiratory rate 18/min
C. Blood pressure 160/94 mm Hg
D. Heart rate 46/min
D. Heart rate 46/min
A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?
A. “Please do not raise your voice at the children. I am the one who left the dishes in the sink.”
B. “If you keep saying that, I will tell everyone what you did last night.”
C. “Can you tell me the reason you get upset each time I go to the mall?”
D. “She is always bossing me around. Should she do that?”
A. “Please do not raise your voice at the children. I am the one who left the dishes in the sink.”
A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?
A. Call the lab to verify the client’s results.
B. Omit the KCL dose and document it as not given.
C. Give the ordered KCL as prescribed.
D. Call the prescribing physician and inform her of the client’s serum potassium level results.
D. Call the prescribing physician and inform her of the client’s serum potassium level results.
A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hours. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
31 drops per minute
A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?
A. Apply a heat lamp twice a day.
B. Reposition the client at least every 2 hours.
C. Massage reddened areas with dressing changes.
D. Clean the wound with hydrogen peroxide solution.
B. Reposition the client at least every 2 hours.
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has re-expanded?
A. Oxygen saturation of 95%
B. Occasional bubbling in the water seal chamber
C. No fluctuations in the water seal chamber
D. No reports of pleuritic chest pain
C. No fluctuations in the water seal chamber
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?
A. Measuring a client’s I&O.
B. Obtaining a client’s weight.
C. Providing postmortem care for a client.
D. Inserting a nasogastric tube for a client.
D. Inserting a nasogastric tube for a client.
A nurse is caring for a client who has a Jackson-Pratt drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
A. To eliminate the need for wound irrigations.
B. To limit the amount of bleeding from the surgical site.
C. To prevent fluid from accumulating in the wound.
D. To provide a means for medication administration
C. To prevent fluid from accumulating in the wound.
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
A. Explain the discharge instructions to the client and parents.
B. Perform a neurovascular assessment.
C. Provide reassurance to the client and parents.
D. Apply an ice pack to the casted leg.
B. Perform a neurovascular assessment.
A nurse is caring for a client who has Cushing’s syndrome. The nurse should recognize that which of the following are manifestations of Cushing’s syndrome? (Select all that apply)
A. Tremors
B. Buffalo hump
C. Moon face
D. Hypertension
E. Purple striae
B. Buffalo hump
C. Moon face
D. Hypertension
E. Purple striae
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
A. The nurse identifies a broken piece of equipment.
B. The nurse has a disagreement with the nursing supervisor about inadequate staffing.
C. A staff member does not show up to work her assigned shift.
D. A client discovers that his dentures are missing.
D. A client discovers that his dentures are missing.
A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?
A. pH 7.26, HCO₃ 14, PaCO₂ 30
B. pH 7.49, HCO₃ 30, PaCO₂ 40
C. pH 7.26, HCO₃ 24, PaCO₂ 46
D. pH 7.49, HCO₃ 24, PaCO₂ 30
A. pH 7.26, HCO₃ 14, PaCO₂ 30
A nurse is caring for a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements can be expected?
A. I can expect to have swelling in my face.
B. I lose protein in my urine.
C. I should increase my sodium intake.
D. I should expect my provider to prescribe a kidney biopsy.
A. I can expect to have swelling in my face.
A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include?
A. Rinse mouth 2 times per day with an alcohol-based mouthwash.
B. Take the medication with an NSAID.
C. Take an antiemetic 1 hour following administration.
D. Drink 2 to 3 liters of water per day.
D. Drink 2 to 3 liters of water per day.
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
A. Long attention span
B. Delayed language development
C. Speaking with direct eye contact
D. Repetitive behavior
E. Playing with toys repetitively
B. Delayed language development
D. Repetitive behavior
E. Playing with toys repetitively
A nurse is teaching a client who is in her first trimester of pregnancy about over-the-counter medications that are a pregnancy risk category B. Which of the following medications should the nurse include?
A. Naproxen
B. Aspirin
C. Ibuprofen
D. Acetaminophen
D. Acetaminophen
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?
A. Restrict head movement.
B. Remove eye patch in one month.
C. Apply cool compresses.
D. Eye drops to constrict the pupils will be prescribed.
A. Restrict head movement.
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
A. Muffled heart sounds.
B. Sudden lethargy.
C. Flattened neck veins.
D. Bradycardia.
A. Muffled heart sounds.
A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?
A. Wash the cord daily with mild soap and water.
B. Apply petroleum jelly to the cord stump.
C. Cover the cord with the diaper.
D. Give a sponge bath until the cord stump falls off.
D. Give a sponge bath until the cord stump falls off.
A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?
A. Walk in front of the client to guide her in moving the walker.
B. Make sure that the upper bar of the walker is level with the client’s waist.
C. Have the client move one leg forward with the walker.
D. Check that the client lifts the walker and then places it down in front of her.
D. Check that the client lifts the walker and then places it down in front of her.
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
A. Assist the client on a bedpan to urinate.
B. Increase the client’s fluid intake.
C. Palpate the client’s uterine fundus.
D. Prepare to administer oxytocin medication.
D. Prepare to administer oxytocin medication.
A nurse is providing teaching for a client who is preparing for a below-the-knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis?
A. You will be fitted for your permanent prosthesis at the time of surgery.
B. You will do muscle strengthening exercises in advance of getting your prosthesis.
C. The structure of the prosthesis will be adjustable depending on what shoe you are wearing.
D. A special pressure dressing will remain in place even when your limb is healed to cushion your prosthesis.
B. You will do muscle strengthening exercises in advance of getting your prosthesis.
A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?
A. It doesn’t appear as though you are feeling anxious.
B. Tell me what has been happening lately.
C. I think you should see a therapist.
D. Do you think your anxiety is worse than everyone else’s?
B. Tell me what has been happening lately.
A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?
A. Treat clients with an antitoxin.
B. Administer antibiotic therapy.
C. Initiate client decontamination.
D. Place the clients in isolation.
B. Administer antibiotic therapy.
A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?
A. I might experience harmless white patches in my mouth.
B. I will expect to have a mild, occasional fever.
C. I will avoid people who have just received a live vaccine.
D. I will limit the use of skin cream to once a week.
C. I will avoid people who have just received a live vaccine.
A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?
A. Dark urine
B. Diarrhea
C. Urticaria
D. Fever
C. Urticaria
A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemicolectomy. Which of the following foods should the nurse instruct the client to avoid?
A. White bread
B. Fresh apples
C. Poached eggs
B. Fresh apples
A nurse is teaching a client who reports taking ginkgo biloba to improve his memory and peripheral arterial disease from atherosclerosis. The nurse should include which of the following potential side effects?
A. Breast enlargement
B. Decreased alertness
C. Bad breath
D. Bleeding gums
D. Bleeding gums
A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?
A. I will reduce my intake of vitamin K-rich foods.
B. I will reduce my intake of sodium.
C. I will decrease my intake of caffeine.
D. I will limit my intake of soft drinks.
A. I will reduce my intake of vitamin K-rich foods.
A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as at risk?
A. Nursing assistant
B. Assembly line worker
C. Truck driver
D. Elementary school teacher
B. Assembly line worker
A nurse is teaching a client who has a new prescription for sucralfate to treat a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will take this medication with an antacid.”
B. “I will reduce my fluid intake with this medication.”
C. “I will take this medication 1 hour before meals and at bedtime.”
D. “I will take this medication as needed to reduce pain.”
C. “I will take this medication 1 hour before meals and at bedtime.”
A nurse educator is teaching a class about medication reconciliation. Which of the following information should the nurse educator include in the teaching?
A. Provide a list of the client’s current medications during the change of shift report.
B. Do not perform reconciliation for a client at discharge from a health care facility.
C. Provide a list of the client’s current medications during admission to a health care facility.
D. Include only prescription medications in the medication reconciliation report.
C. Provide a list of the client’s current medications during admission to a health care facility.
A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
A. Sleepy, but arousing when her name is called.
B. Respiratory rate 8/min.
C. Pain level of 6 on a scale from 0 to 10.
B. Respiratory rate 8/min.
A nurse is teaching a client about the uses of chamomile. Which of the following information should the nurse include in the teaching?
A. Chamomile may act as a calming agent.
B. Chamomile has anti-inflammatory properties beneficial for treating skin disorders.
C. Chamomile decreases cholesterol levels.
D. Chamomile can reduce nausea and vomiting.
A. Chamomile may act as a calming agent.
A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child’s cooperation?
A. Offer the child a choice of taking the medication with juice or water.
B. Tell the child it is candy.
C. Tell the child he will have to have a shot instead.
D. Hide the medication in a large dish of ice cream.
A. Offer the child a choice of taking the medication with juice or water.
A nurse is caring for a child who is allergic to penicillin. The nurse should clarify which of the following prescriptions with the provider?
A. Erythromycin
B. Gentamicin
C. Amphotericin B
D. Amoxicillin-clavulanate
D. Amoxicillin-clavulanate
A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep?
A. Provide bedtime rituals.
B. Encourage play exercises in the evening.
C. Explain the source of the toddler’s fears.
D. Turn off the room light.
A. Provide bedtime rituals.
A nurse is observing a client’s nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?
A. Nonverbal communication conveys less truth than what the client states verbally.
B. The client enacts nonverbal communication consciously.
C. The client’s sociocultural background influences nonverbal communication.
D. Nonverbal communication is a poor reflection of what the client feels.
C. The client’s sociocultural background influences nonverbal communication.
A nurse is caring for a client who is postoperative following a laminectomy.
Exhibits
Select the 3 findings that require immediate follow-up:
Nurses’ Notes
Client is 12 hours postoperative following a laminectomy. Client is alert and oriented to person, place, and time. Incision site has purulent drainage. Redness and warmth around the incision site also noted. Client reports pain as a 7 on a scale of 0 to 10. Crackles heard upon auscultation in posterior lungs and client is dyspneic. Abdomen soft and nontender, bowel sounds are hypoactive in all four quadrants. Pedal pulses are +2 bilaterally. Capillary refill is less than 2 seconds.
Vital signs obtained:
Blood pressure: 138/72 mmHg
Heart rate: 82/min
Respiratory rate: 18/min
Temperature: 38.3°C (101.1°F)
Oxygen saturation: 94% on room air
A. Pain level
B. Blood pressure
C. Lung sounds
D. Incision site
E. Pedal pulses
A. Pain level
C. Lung sounds
D. Incision site
A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)
Nurses Notes
0800: Client is alert and oriented to person, place, and time. Seizure pads placed on the client’s bed. Suction equipment is at the client’s bedside and functioning. Oxygen equipment is at the client’s bedside.
1000: Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client is incontinent of urine and unresponsive to commands.
1004: Client’s jerking contractions of arms and legs continue. Yellow watery emesis approximately 45 mL on gown; 2 to 5 second long periods of apnea.
A. Time the duration of the seizure.
B. Administer supplemental oxygen to the client.
C. Place a tongue depressor in the client’s mouth.
D. Turn the client to the side.
E. Restrain the client.
A. Time the duration of the seizure.
B. Administer supplemental oxygen to the client.
D. Turn the client to the side.
A nurse is caring for a 75-year-old male patient who is experiencing difficulty breathing and shortness of breath.
The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up)
Medical History
Nurses’ Notes
75-year-old male who reports increased dyspnea for 4 days. Denies cough or fever.
Past medical history: Two-pack-a-day smoker for 50 years. Diagnosed with lung cancer 4 years ago and treated. Over the last year, has developed frequent pleural effusions treated with thoracentesis. Hypertension.
Surgical history: Right lower lobectomy 4 years ago. Left hernia repair 15 years ago.
A. Diminished lung sounds
B. Heart rate 110/min and regular
C. Oxygen saturation of 95%
D. Subcutaneous emphysema
E. Trachea midline
F. Puncture site dry
A. Diminished lung sounds
B. Heart rate 110/min and regular
D. Subcutaneous emphysema
A nurse in an outpatient mental health clinic is treating a client who has bulimia nervosa.
A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic response to the treatment plan.
Basic Metabolic Profile
Physical Examination Findings
June 1: Basic Metabolic Profile:
Creatinine 1.0 mg/dL (0.5 to 1.0 mg/dL) Critical values: > 4 mg/dL
BUN 28 mg/dL (10 to 20 mg/dL) Critical values: > 100 mg/dL
Potassium 3.2 mEq/L (3.5 to 5 mEq/L) Critical values: > 100 mg/dL
12 Lead ECG:
Sinus rhythm with frequent premature ventricular contractions (PVCs), rate 72
June 15: Basic Metabolic Profile:
Creatinine 0.8 mg/dL (0.5 to 1.0 mg/dL) Critical values: > 4 mg/dL
BUN 26 mg/dL (10 to 20 mg/dL) Critical values: > 100 mg/dL
Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Critical values: > 100 mg/dL
A. Potassium level
B. ECG report
C. BUN level
D. Laxative usage
E. overeating cycle/purging
F. Coping skills
A. Potassium level
D. Laxative usage
E. overeating cycle/purging
F. Coping skills
A nurse is caring for a client who has sickle cell disease.
Nurses’ Notes
0800:
Client reports fatigue, muscle weakness, joint pain, and dyspnea.
Sclerae is jaundiced. 2.5 cm (1 in) by 2.5 cm (1 in) open ulcer noted on inner left ankle.
Vital Signs
0800:
Temperature 37.5° C (99.5° F)
Blood pressure 122/68 mm Hg
Heart rate 95/min
Respiratory rate 28/min
Oxygen saturation 95% on room air
1000:
Temperature 37.5° C (99.5° F)
Blood pressure 88/56 mm Hg
Heart rate 112/min
Respiratory rate 26/min, labored
Oxygen saturation 90% on room air
Diagnostic Results
1000:
Hct 26% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, or leukemia. Each finding may support more than 1 disease process.
Options Sickle Cell disease Iron Deficiency Anaemia Leukemia
A . Joint pain
B . Heart Rate at 1000
C . Respiratory status
D. Jaundice
E. Ankle ulcer
Sickle Cell
- resp status
- joint pain
- HR
- jaundice
- ankle ulcer
Leukemia
- resp status
- joint pain
- HR
- jaundice
Iron Deficiency
- resp status
- HR
A nurse is caring for a 78-year-old client who was recently admitted from the emergency room and is reporting weakness.
Drag words from the choices below to fill in each blank in the following sentence.
The nurse has reviewed the client’s medical record. The client is at risk for developing
Alert and oriented x 3
Reports weakness and dizziness
Skin pale and cool, poor skin turgor
Mucous membranes dry with a white coating
Denies nausea
Lungs clear to auscultation
Abdomen soft with hyperactive bowel sounds x 4
Reports diffuse abdominal tenderness on palpation
Reports 3 watery bowel movements in the last 8 hours
Urine dark yellow in color
Output 30 mL/hr
Sodium 149 mEq/L (136 to 145 mEq/L)
Potassium 5.0 mEq/L (3.5 to 5 mEq/L)
Chloride 102 mEq/L (98 to 106 mEq/L)
Magnesium 1.8 mEq/L (1.3 to 2.1 mEq/L)
Total calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)
Osmolality 301 mOsm/L (285 to 295 mOsm/L)
ABGs
pH 7.33 (7.35 to 7.45)
PCO2 35 mm Hg (35 to 45 mm Hg)
HCO3 19 mEq/L (21 to 28 mEq/L)
PO2 92 mm Hg (80 to 100 mm Hg)
Hypotension and Metabolic Acidosis
A nurse is caring for a client who is pregnant and was admitted 6 days ago for preterm prelabor rupture of membranes (PPROM).
A nurse is performing a follow-up assessment on the client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Medical History
Admission Assessment
Physical Examination
Vital Signs
Estimated gestational age: 33 weeks and 3 days.
Smokes tobacco regularly; denies alcohol or other substance use.
Chronic hypertension. Takes Labetalol 100 mg PO BID.
Prenatal ultrasounds show no fetal or placental abnormalities.
Pregnancy history includes one term vaginal delivery and two preterm vaginal deliveries.
actions to take:
- prepare to administer gentamicin IV
- educate the client on the process of inducing labor
condition:
Chorioamnionitis
parameters to monitor:
- maternal body temp
- uric acid levels
A nurse is admitting a client to a medical-surgical unit following a fall at home.
The nurse is discussing the client’s treatment plan with a provider. For each potential provider’s prescription, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Medical History
Diagnostic Results
Nurses’ Notes
Vital Signs
Heart failure
Iron-deficiency anemia
Spironolactone 50 mg PO BID
Ferrous sulfate 60 mg PO QD
Options Anticipated Nonessential Contraindicated
A . Administer spironolactone
B . Administer an IV fluid bolus
C . Obtain an x-ray of the right hip
D . Administer an iron supplement
E . Obtain the client’s weight
F . Administer supplemental oxygen
anticipated:
B . Administer an IV fluid bolus
C . Obtain an x-ray of the right hip
E . Obtain the client’s weight
contraindicated:
A . Administer spironolactone
nonessential:
D . Administer an iron supplement
F . Administer supplemental oxygen
A nurse is teaching a client who is postpartum about caring for their newborn’s umbilical cord. Which of the following instructions should the nurse include?
A. Cover the cord with the upper edge of the diaper.
B. Apply petroleum jelly around the cord with every diaper change.
C. Report minor bleeding when the cord’s stump falls off.
D. Wash the area around the base of the cord with water.
D. Wash the area around the base of the cord with water.
A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “A health care surrogate must be a family member.”
B. “The client can resume control of health care after a temporary loss of competency.”
C. “The provider will choose a client’s health care surrogate.”
D. “The provider can go against the client’s wishes regarding advance directives.”
B. “The client can resume control of health care after a temporary loss of competency.”
A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?
A. Suggest that the client attend adult day care three times per week.
B. Review assisted living accommodations with the client.
C. Discuss a long-term care referral for the client with the provider.
D. Instruct the client about the use of telehealth services.
D. Instruct the client about the use of telehealth services.
A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler’s diet?
A. A bologna sandwich on rye bread
B. corn tortilla with black beans
C. Whole wheat pasta with shrimp
D. Low sodium vegetable soup with barley
B. corn tortilla with black beans
a nurse is assessing a client who has schizophrenia prior to administering the client’s next dose of clozapine. Which of the following findings should the nurse report to the provider?
A. Diaphoresis
B. Fever
C. Polyuria
D. Diarrhea
B. Fever
A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?
A. The client’s heart rate increases by 10/min.
B. The client’s systolic blood pressure decreases by 25 mm Hg.
C. The client’s diastolic blood pressure increases by 10 mm Hg.
D. The client reports heart palpitations.
B. The client’s systolic blood pressure decreases by 25 mm Hg.
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?
A. Request insertion of a tracheostomy tube.
B. Suction the client’s airway.
C. Tighten the tubing connections.
D. Look for a leak in the tube’s cuff.
B. Suction the client’s airway.
A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?
A. Peanut butter
B. Crispy rice bar
C. Scrambled eggs
D. Soda crackers
C. Scrambled eggs
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?
A. Lubricate the catheter with water-soluble gel.
B. Position the sterile drape leaving the perineum exposed.
C. Cleanse the client’s meatus with antiseptic solution.
D. Attach a prefilled syringe to the catheter inflation hub.
C. Cleanse the client’s meatus with antiseptic solution.
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of “tightness” in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?
A. Acute hemolytic
B. Allergic
C. Bacterial
D. Febrile nonhemolytic
A. Acute hemolytic
A nurse is teaching a client how to care for their behind-the-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching?
A. “I’ll replace the batteries every 2 weeks.”
B. “I’ll use isopropyl alcohol to clean my hearing aids.”
C. “I’ll clean my ear with cotton swabs before I insert my hearing aids.”
D. “It will disconnect the battery when I remove my hearing aids.”
D. “It will disconnect the battery when I remove my hearing aids.”
A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include?
A. Take antacids that contain mint for heartburn.
B. Avoid consuming foods containing chocolate.
C. Increase dietary intake of citrus fruits.
D. Lie down for 30 min after eating a meal.
B. Avoid consuming foods containing chocolate.
A nurse in a provider’s office is talking with an older adult client who tells the nurse that they fear they are “aging badly” and feel “so useless.” Which of the following assessment questions is the nurse’s priority?
A. “Did anything in particular make you feel this way?”
B. “Do you ever think about harming yourself?”
C. “How long have you had these feelings of uselessness?”
D. “Would you tell me more about the changes you see in your body?”
B. “Do you ever think about harming yourself?”
A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?
A. “Empty your ostomy pouch when it is half full.”
B. “Notify the provider if your stoma becomes pink and moist.
C. “Use a moisturizing soap to cleanse your stoma.”
D. “Apply sterile gloves when changing your ostomy pouch.”
A. “Empty your ostomy pouch when it is half full.”
A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?
A. Initiate IV access on the palmar side of the client’s wrist.
B. Choose the client’s dominant arm for IV access whenever possible.
C. Select a site proximal to previous venipuncture sites.
D. Insert a larger gauge IV catheter to prevent phlebitis.
C. Select a site proximal to previous venipuncture sites.
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?
A. “Think about a positive outcome to a stressful situation.”
B. “Tighten a muscle group, then release the tension and move to the next one.”
C. “Focus on a pleasant memory and express your emotions in writing.”
D. “Picture taking the stress you feel and pushing it down and out of your feet.”
B. “Tighten a muscle group, then release the tension and move to the next one.”
A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?
A. Provide the client with a list of eligible individuals who can serve as a health care proxy.
B. Document in the client’s medical record if the client has advance directives.
C. Provide end-of-life education if the client has a terminal illness.
D. Ensure the client has an attorney to contact for assistance with end-of-life documents.
B. Document in the client’s medical record if the client has advance directives.
A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?
A. Establish a new routine for the child to follow while in the facility.
B. Encourage the child to play with toys such as a pounding board.
C. Use medical terminology when discussing procedures with the child.
D. Perform the morning assessments when the parent is not in the room.
B. Encourage the child to play with toys such as a pounding board.
A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?
A. Measure the legs with a tape measure to determine stocking size.
B. Remove the stockings every 24 hr.
C. Massage the legs before applying the stockings.
D. Fold the stockings at the top if they are too long.
A. Measure the legs with a tape measure to determine stocking size.
A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A. Remove the old dressing.
B. Create a sterile field.
C. Apply precut gauze pads to the site.
D. Mask self and the client.
D. Mask self and the client.
A. Remove the old dressing.
B. Create a sterile field.
C. Apply precut gauze pads to the site.
A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home. Which of the following instructions should the nurse include?
A. Report sudden, persistent headaches.
B. Avoid meningococcal immunizations.
C. Apply cold compresses to painful areas.
D. Restrict fluid intake during times of stress.
A. Report sudden, persistent headaches.
A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?
A. “You might feel a bit confused for a few hours after the procedure.”
B. “You might notice some changes in your-voice after the procedure.”
C. “You’ll wake up about 30 minutes after the procedure.”
D. “You can expect to feel some pulsation’s in your neck during the procedure.”
A. “You might feel a bit confused for a few hours after the procedure.”
A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?
A. 4+ deep-tendon reflexes
B. Urine output 2.500 mL/day
C. Scant lochia rubra with a few small clots
D. Bilateral ankle edema
A. 4+ deep-tendon reflexes
A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client’s blood pressure is 88/50 mm Hg and their abdomen is rigid. The nurse should identify these findings as indicating which of the following complications?
A. Placental abruption
B. Uterine rupture
C. Placenta previa
D. Amniotic fluid embolus
A. Placental abruption
A nurse is evaluating the progress of a school-age child who takes methylphenidate. Which of the following findings indicates the effectiveness of the medication?
A. Decreased impulsiveness
B. Increased urine output
C. Increased appetite
D. Decreased abdominal pain
A. Decreased impulsiveness
A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
A. The nurse wears an N95 respirator when performing client care.
B. The nurse places the client on airborne precautions.
C. The nurse ensures the client’s room maintains a positive airflow.
D. The nurse has the client wear a mask for transport to radiology.
C. The nurse ensures the client’s room maintains a positive airflow.
A nurse is teaching a class about providing care within the legal stope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?
A. Changing the inner cannula on a tracheostomy
B. Administering a platelet transfusion
C. Irrigation of an external ear canal
D. Inserting a tunneled central venous catheter
D. Inserting a tunneled central venous catheter
A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?
A. Contact
B. Airborne
C. Protective environment
D. Droplet
D. Droplet
A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client’s feedings?
A. Add water to the formula.
B. Reposition the NG tube.
C. Increase the rate of formula delivery.
D. Switch to a lactose-free formula.
A. Add water to the formula.
A nurse is performing an eye examination on a client. Which of the following findings should indicate to the nurse that the client might have cataracts?
A. Loss of central vision
B. Increased intraocular pressure
C. Decrease in peripheral vision
D. A bluish-white colored pupil
D. A bluish-white colored pupil
A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referrals should the nurse anticipate for this client?
A. Occupational therapist
B. Chiropractor
C. Acupuncturist
D. Physical therapist
D. Physical therapist
A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include?
A. “Eat a high-fat snack at bedtime.”
B. “Sip carbonated beverages throughout the day
C. “Drink hot herbal tea to relieve symptoms.
D. “Lie down for 30 min after meals.”
C. “Drink hot herbal tea to relieve symptoms.
A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?
A. “I can expect my eyelids to be bruised after this procedure.
B. “I will see dark spots in my vision after this procedure.”
C. I will receive general anesthesia for this procedure.”
D. I know the provider will replace the lens in my eyes during this procedure.”
D. I know the provider will replace the lens in my eyes during this procedure.”
A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, “I’m afraid they will give me drugs that put me to sleep.” Which of the following statements should the nurse make?
A. “You will need to rest so that you can recover from the episode that brought you here.”
B. “I will make sure that we respect your right to refuse medications.
C. “It’s not your choice to be here, so you have to accept the treatment we plan for you.”
D. “Why do you think your provider will prescribe you medications that will make you sleep?”
B. “I will make sure that we respect your right to refuse medications.
A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?
A. Observe the client for 1 hr after meals.
B. Obtain the client’s vital signs every other day.
C. Weigh the client every 48 hr.
D. Allow the client to eat meals in their room.
A. Observe the client for 1 hr after meals.
A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?
A. Human papillomavirus (HPV)
B. Rotavirus
C. Herpes zoster
D. Diphtheria, tetanus, and acellular pertussis (DTaP)
C. Herpes zoster
A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications?
A. Atropine
B. Flumazenil
C. Naloxone
D. Activated charcoal
B. Flumazenil
A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over- the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?
A. Iron
B. Calcium
C. Magnesium
D. Potassium
D. Potassium
A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?
A. Preeclampsia
B. Transverse fetal lie
C. Post-term pregnancy
D. Intrauterine growth restriction
B. Transverse fetal lie
A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?
A. Lift the traction weights when repositioning the child in bed.
B. Have the child rate their level of pain ever-8 hr.
C. Monitor the neurovascular status of the child’s lower extremities every 12 hr.
D. Educate the child’s guardians about pin site care prior to discharge.
D. Educate the child’s guardians about pin site care prior to discharge.
A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?
A. Hypertension
B. Headache
C. Insomnia
D. Tinnitus
B. Headache
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
A. Frequent swallowing
B. Dark brown emesis
C. Sore throat
D. Blood-tinged mucus
A. Frequent swallowing
A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?
A. Provide the client with a low-protein diet.
B. Ambulate the client every 4 hr.
C. Ensure that the side rails are up on the client’s bed.
D. Check the fetal heart rate twice daily.
C. Ensure that the side rails are up on the client’s bed.
A nurse is assessing a client who is taking digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
A. Hearing loss
B. Insomnia
C. Tachycardia
D. Blurred vision
D. Blurred vision
A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will take the medication in the morning.”
B. “I will avoid crushing this medication.”
C. “I will take the medication on an empty stomach.”
D. “I will expect to gain weight.”
B. “I will avoid crushing this medication.”
A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client’s bedside?
A. Wire cutters
B. Montgomery straps
C. Tracheostomy tray
D. Padded clamp
D. Padded clamp
A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
A. A client who has a right peripherally inserted central catheter
B. A client who had a right hemisphere stroke
C. A client who had blood drawn from the right antecubital area 1 hr ago
D. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm
A. A client who has a right peripherally inserted central catheter
A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client’s plan of care?
A. Attach a dosimeter to the client’s gown.
B. Strain the client’s urine.
C. Limit each of the client’s visitors to 2 hr per day.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client.
A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
A. Instruct a client on the use of an incentive spirometer.
B. Insert an NG tube for a client who requires enteral feedings.
C. Obtain a client’s vital signs every 4 hr.
D. Record a client’s intake after each meal,
E. Transfer a client to physical therapy.
C. Obtain a client’s vital signs every 4 hr.
D. Record a client’s intake after each meal,
E. Transfer a client to physical therapy.
A school nurse is using the Weber’s test to check a child’s hearing acuity. Which of the following actions should the nurse take?
A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child’s ears.
B. Measure the amount of time the child can hear the sound.
C. Obtain a tympanogram reading prior to initiating the test.
D. Place a vibrating tuning fork on the top of the child’s head.
D. Place a vibrating tuning fork on the top of the child’s head.
A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?
A. “Hold your daughter when your son first meets her.”
B. “Plan for your son to meet his sister for the first time at home.”
C. “Give your son a little gift from his new sister.”
D. “Give your son plenty of ‘alone time’ with his sister.”
C. “Give your son a little gift from his new sister.”
A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client’s risk for acquiring a UTI?
A. Obtain urinary samples by disconnecting the tubing connections.
B. Secure the catheter to the client’s thigh.
C. Keep the urinary bag at bladder level when ambulating.
D. Loop the tubing so that it is lower than the collection bag.
E. Loop the tubing so that it is lower than the collection bag.
B. Secure the catheter to the client’s thigh.
A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?
A. Hazelnuts
B. Almonds
C. Bananas
D. Strawberries
C. Bananas
A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?
A. “Place the patch on your upper arm.”
B. “Replace a dislodged patch onto the same location.”
C. “Apply the patch prior to traveling.”
D. “Store unused patches in the refrigerator.”
C. “Apply the patch prior to traveling.”
A nurse is teaching a client who has a new prescription for sertralihe to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
A. Insomnia
B. Constipation
C. Dry mouth
D. Excessive sweating
D. Excessive sweating
A nurse is teaching a client who is pregnant about nonstress testing. Which of the following statements by the client indicates an understanding of the teaching?
A. “This test will tell me if my baby has a genetic problem.”
B. “I will get oxytocin during this test.”
C. “During this test. I must not eat or drink anything.”
D. “During this test. I will push a button if my baby moves.”
C. “During this test. I must not eat or drink anything.”
A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?
A. Hepatitis A
B. Rotavirus
C. Influenza
D. Varicella
B. Rotavirus
A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?
A. Chart a summary of the data at the change of the shift.
B. Note whether the client has a living will.
C. Document the client’s vital signs obtained by assistive personnel.
D. Begin charting with an evaluation of the data.
D. Begin charting with an evaluation of the data.
A charge nurse is observing assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?
A. Performing a simple dressing change on a client’s foot
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile
C. Providing postmortem care for a client who has recently died
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?
A. Abdominal distention
B. Watery stool
C. Dizziness
D. Oliguria 2%
A. Abdominal distention
A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?
A. The client reports that the restraints are too tight.
B. The client has been in the restraints for 4hr.
C. The client is able to calmly follow commands.
D. The client can explain the reasons for their behavior.
C. The client is able to calmly follow commands.
A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?
A. Wear a bra with wire support.
B. Use deodorant under the affected arm.
C. Begin ball squeezing exercises.
D. Avoid using the affected arm for eating.
D. Avoid using the affected arm for eating.
A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding their newborn. Which of the following instructions should the nurse include in the teaching?
A. “You should wear a snug-fitting bra continuously for 72 hours.”
B. “You should apply moist heat to your breasts four times per day.”
C. “You should limit your fluid intake to 1 liter per day.”
D. “You should manually express milk when engorgement occurs.”
A. “You should wear a snug-fitting bra continuously for 72 hours.”
A charge nurse observes smoke coming from a trash receptacle in the unit’s waiting room. Which of the following actions should the nurse take first?
A. Activate the fire alarm system.
B. Evacuate clients from the area.
C. Obtain and use a fire extinguisher.
D. Close the doors and windows on the unit.
B. Evacuate clients from the area.
A nurse is caring for a client who is experiencing seizures due to alcohol withdrawal. Which of the following medications should the nurse plan to administer?
A. Disulfiram
B. Acamprosate
C. Diazepam
D. Naltrexone
C. Diazepam
A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take?
A. Tell the client to gently stroke their lower abdomen.
B. Turn on the faucets in the client’s sink.
C. Pour cool water over the client’s perineum.
D. Instruct the client to lean slightly backward.
A. Tell the client to gently stroke their lower abdomen.
A nurse is creating an incident report due to an accidental omission of a client’s dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?
A. “Incident report completed. A copy will be placed in the client’s medical record.
B. “Prescribed dressing change was accidentally omitted during the previous shift.”
C. “A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow.”
D. “Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.
B. “Prescribed dressing change was accidentally omitted during the previous shift.”
A nurse in an acute mental health facility is teaching a client about the potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that they may feel lightheaded, but that it should not affect their memory. The nurse is demonstrating which of the following ethical principles?
A. Veracity
B. Fidelity
C. Beneficence
D. Autonomy
A. Veracity
