NURS 203:Health Education Systems Incorporated: HESI 2017

1. A nurse performs a Tinetti assessment on an 82-year-old client an ……12 and a gait score of 8. a. Expected results for an elderly adult. b. Likely onset of Parkinson’s disease c. Increased risk for falling d. Need for ...

1. A nurse performs a Tinetti assessment on an 82-year-old client an ……12 and a gait score of 8. a. Expected results for an elderly adult. b. Likely onset of Parkinson’s disease c. Increased risk for falling d. Need for a walker to aid in ambulation 2. The daughter of an older woman, who has Parkinson’s disease, calls the clinic her mother has been confused for the past week. What actions should the nurse take? (Select all that apply.) a. Encourage increased intake of high protein foods. b. Determine if the mother has recently experience a fall c. Ask if the mother is experiencing any pain with urination d. Instruct the daughter to check her mother’s temperature. e. Review the client’s current food and medication allergies 3. The healthcare provider prescribes a STAT computerized tomography (CT) scan without contrast for a client who is exhibiting signs of an acute change in level of consciousness. The nurse is caring for two additional intensive care clients and has an unlicensed assistive personnel (UAP) assigned to assist with the delivery of care. a. instructs the UAP to transport the client to CT scan with a cardiac monitor. b. Administer scheduled medications prior to transporting the client to CT scan c. Hand-off care of additional clients then transport client to CT scan without delay. d. Call the client’s healthcare power of attorney for permission to obtain CT scan. 4. A female client arrives by car to the emergency department and tells the nurse that she was just stung by a bee on her neck while gardening. The client informs the nurse that her epinephrine pen had expired. Which assessment finding warrants immediate intervention by the nurse? a. Raise whelps over chest area. b. Audible upper airway stridor c. 02 saturation 88% on room air d. Complaint of chest heaviness 5. A client newly diagnosed with Type 2 diabetes mellitus (DM receives a prescription for..50 mg PO BID. The client has no history of hypertension, and the baseline blood pressure (BP) 132/78 mm Hg. Which action should the nurse implement? a. Withhold the medication if BP is within normal range. b. Examine the medical history for hypertensive risk factors. c. Administer antihypertensive medication as prescribed d. Assess the client for signs and symptoms of hypertension. 6. The family of a client with multi-organ failure presents a living will requesting measures. The client is confused and moaning, has crackles through all lung field, and a urine output of 20 ml/hour. Which need is most important for the nurse to include in this client’s plan of care? a. Comfort b. Oxygenation c. Hydration d. Nutrition 7. Which client’s laboratory value requires immediate intervention by a nurse? a. A client with hepatitis who is jaundice and has a bilirubin level that is 4 times the normal value. b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday c. A client with cancer who has an absolute count of neutrophils today and had 2,000 yesterday. d. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of grams. 8. The nurse is planning care for a client who is receiving 24-hour via a central line. What nursing measure is essential for this client? a. Monitor the blood glucose frequently. b. Assess the peripheral IV site q6h. c. Change the transparent dressing daily d. Change Y-tubing q8h while administering TPN 9. After teaching a client newly diagnosed with cholecystitis nurse evaluates the client’s learning. Which food choices Nurse that teaching has been successful? a. Pasta with herbal butter and no meat sauce. b. Canned vegetable with additional table salt. c. Citrus fruit and melon with a salt substitute. d. Whole milk and daily serving of ice cream 10. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for the treatment? a. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider. b. Describe the signs of goiter because this is a common side effect of radioactive iodine. c. Explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately. d. Explain the need for using lead shields for 2 to 3 weeks after the treatment. 11. Following discharge teaching, a male client with a duodenal ulcer tell the nurse that he will drink plenty of dairy products, such as milk to help coat and protect his ulcer. What is the best followed up action by the nurse? a. Remind the client that is also important to switch to decaffeinated coffee and tea. b. Reinforce this teaching by asking the client to list dairy foods that he might select. c. Suggest that the client also plan to eat frequent small meals to reduce discomfort d. Review with the client the need to avoid foods that are rich in milk and cream 12. The nurse is taking the history of a young adult female who is 5 feet 3 inches (160 cm) tall and weighs 90 pounds (40.9 kg). Which reported finding is most important for the nurse to address immediately? a. Severe constipation. b. Absence of menstrual cycle. c. Seen walking fast outdoors. d. Intermittent palpitations. 13. During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personal(UAP), reports to the nurse that a healthcare provider is on the telephone and wisher to prescribe a PRN dose of an oral over-the counter laxative for the client who is constipated. What instruction should the RN provide the unit clerk? a. Remain with this client and monitor the vital signs while the RN takes. b. Ask the healthcare provider to remain on “hold” until the RN can confirm the prescription. c. Be sure to write down what is prescribed and then repeat it back to the healthcare provider. d. Tell the healthcare provider the RN will return the phone call as soon as possible. 14. When administering indomethacin (Indocin) to a premature infant who has patent ductus arteriosus, the nurse should anticipate which outcome? a. Decreased cardiac murmur. b. Decreased urinary output. c. Increased number of red blood cells. d. Increased respiratory effort 15. A client in the third trimester of pregnancy complains of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. What intervention should the nurse implement? a. Ask a nurse with more experience to validate the costal angle finding. b. Ask the healthcare provider to evaluate the client’s respiratory status. c. Record the respiratory finding in the client’s record as normal. d. Examine the client for signs of tissue anoxia, such as pallor. 16. The nurse observes an elderly male client walking aimlessly in the hallway and staring straight ahead blankly. How should the nurse enter computer documentation of this finding? a. Demonstrates signs of early dementia. b. Appears confused and depressed. c. Wandering behavior with flat affect. d. Ambulatory and disoriented to place. 17. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personal (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply). a. Shuffling gait. b. Diminished visual acuity. c. Syncope when bending. d. hands tremors. e. Urinary incontinence. 18. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? a. An 82 years old client with Alzheimer disease and newly fractured femur who has a Foley catheter and soft wrist restraints applied b. A 63 years old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline locked peripheral intravenous catheter c. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter d. A 48 years old marathon runner with central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race 19. Which long term outcomes is most important for the nurse include in the plan of care for an older adult client with chronic pyelonephritis a. Maintains blood pressure within normal limits b. Restricts fluid intake to 1L/day c. Measure oral temperature daily d. Manages activities of daily living independently 20. Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? a. Potatoes, low fat breads, and applesauce b. Chicken, rice and wheat products c. Lean beef, salads, and baked potatoes d. Oatmeal, raisins and fruit with skin 21. An adult female client with a history of fibrocystic breast disease is seeking care because of a pea- sized, painful lump she discovered in her left breast three weeks ago. She is anxious, and states that she is sure she has cancer. Which response should the nurse provide to this client? a. ‘’Follow- up assessment should have been sought as soon as the lump was noticed” b. “Cancer is possible but the lump requires a biopsy by the healthcare provide for confirmation” c. “Risk for cancer is low but seeking more information about the lump was the right decision” d. “No cause for worry since cancer for worry since cancer rarely ever presents as a small, painful lump” 22. A male client with cirrhosis has ascites and reports feelings short of breath. The client is in a Semi-Fowler’s position with his arms at his side. What action should the nurse implement? a. Elevate the client’s feet on a pillow while keeping the head of the bed elevated b. Reposition the client in a side- lying position and support his abdomen with pillows c. Place the client in a shock position and monitor his vital signs at frequent intervals d. Raise the head of the bed to a fowler’s position and support his arms 23. The nurse us providing dietary instruction for a client who is being do calcium oxalate renal stone. Which food should the nurse instruct the client? a) Fish b) Spinach salad c) Sweet potatoes d) Bananas 24. Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a- Serum electrolytes b- Capillary blood glucose c- Serum liver enzymes d- Complete blood count 25. An adult male is lying in bed asks the nurse for assistance with walking. The client has privileges, but he is weak and easily fatigue. To reduce the orthostatic hypotension, which action should the nurse take a. Offer the client a urinal to use while standing closed the bedside b. Move legs through passive range of motion while the client is lying down bathroom c. Have client dangle his legs over the bed before standing d. Apply a pulse oximeter to measure to measure oxygen saturation during ambulation 26. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites a malnutrition. The client is drowsy but responds to verbal stimuli and report recently spitting blood. What assessment finding warrants immediate intervention by the nurse? a. Round and tight abdomen b. Pitting edema in lower legs c. Bruises on arms and legs d. Capillary refill of 8 seconds. 27. A client’s tumor measure 2 cm before and after receiving a course of radiotherapy. What physiological mechanism renders this response to radiation therapy for cancers? a. Reduction of contact inhibition results in cells dearth by phagocytosis. b. Production of ionizing energy damages DNA, hence stops replication c. Cellular anchorage that is necessary for cancer cell growths is removed d. Cell growth is disrupted during the resting of the cell cycle 28. Following an amniocentesis a client verbalizes several complains. What complaint indicated the nurse that the client is experiencing a complication for amniocentesis? a- Epigastric pain b- Increased fetal movement c- Headaches and blurred vision d- Low back pain with pelvic cramping 29. A 4 years old girl returns to the pediatrician’s office for postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child? a. Ignores other in the play area b. Draws picture of self with facial features c. Sits quietly in her mother’s lap d. “Talks” to an imaginary friend 30. When assessing an infant with severe diarrhea, the nurse should observe for which potential change in breathing pattern? a. Expiratory wheezing b. Kussmaul respirations c. Audible rhonchi d. Cheyne- Stokes respirations 31. The nurse is administering 18 units of Humulin N at 1630 to a client with type 2 diabetes. Which intervention is most import for the nurse to implement? a. obtains the client’s blood glucose level prior to eating dinner. b. Assess the client serum potassium level prior to administering insulin. c. Encourage the client to ambulate in the hall prior to going to sleep. d. Ensure that the client eats the bedtime snack provided by dietary. 32. The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching a 24- gauge needle. What action should the charge nurse take? a. Tell the new nurse to leave and complete the procedure b. Direct the nurse to remove the needle before the procedure c. No corrective action is needed by the nurse d. Instruct the nurse to use water with 5% dextrose (D5W) 33. In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At what location should the nurse observe for this finding? 34. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? a. Increase the liter flow of oxygen. b. Encourage the client to take deep breaths. c. Document the assessment data. d. Remove the mask to deflate the bag. 35 An older female client with progressive dementia fell and broke her hip one week ago. The client is unable communicate her level of pain. Which intervention is most important for the nurse include in the client’s plan of care. a. Encourage client to eat at meal time b. Administer pain medication regularly c. Explain procedures shortly before implementation d. Provide non- pharmacological pain management 36. A nurse is assessing a client who has an arteriovenous (AV) in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. What interventions should the nurse implement? a. Document the findings b. Assess the client’s temperature c. Elevate the extremity d. Apply gentle pressure 37. A client with acute renal failure is scheduled to receive a dose of oral sodium polystyrene sulfonate. The client’s current serum potassium level is 5.2 mfq/l and current serum sodium level is 148 mE q/L. what is the priority nursing action? a. Evaluate the client’s fluid intake and output record. b. Review salt intake guidelines with the client. c. Notify the healthcare provider of the electrolyte values d. Administer the medication as scheduled. 38. The nurse is planning care for a newborn infant scheduled for a cardiac catheterization; Occurrence poses the greatest risk for this child? a. Loss of pulses proximal to the entry site of the care cardiac catheter. b. Acute hemorrhage from the entry site of the catheter after the procedure c. Allergic response to the plastics in the catheter used for catherization. d. Fever associated with nausea and vomiting after the procedure 39. A male client with chronic kidney disease (CKD) arrives at the clinic complaining of shortness of breath on exertion and extreme weakness. The nurse auscultates his lungs and obtains his vital… a. Creatinine 14 mg/dl b. Blood urea nitrogen c. Potassium 6.5 d. Bicarbonate 40. A client recently diagnosed with early stage Alzheimer’s disease receives a prescription of donepezil (Aricept), an acetyl cholinesterase inhibitor. Which content should the nurse... The client medication teaching? a. Explain that the pituitaries has prescribed the maximum dose and will decrease it gradually b. Instruct the client to get monthly liver function studies to assess for liver failure. c. Encourage the client to avoid foods high in vitamin K, such as green leafy vegetables d. Discuss the fact that Aricept may slow the progression of the disease over the next year. 41. A client with a history of heart failure and type 1 diabetes mellitus is admitted with unstable angina. Which problem requires the most immediate intervention by the nurse? a. Fluid volume excess b. Acute angina pain c. Fatigue d. Activity intolerance 42. A client who takes nonsteroidal antiflammatory drugs (NSAIDs) every day for rheumatoid arthritis is being treated for anemia. Which intervention is most important for the nurse to include in the plan of care? a. Monitor liver function test result b. Observe for gastrointestinal bleeding c. Protect skin from bruising d. Offer dietary selections rich in iron 43. A client diagnosed with pancreatitis complains of severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and learning forward. What action should the nurse implement? a. Raise the head of the bed to a 90 degrees’ angle b. Provide a bedside table for a client to lean across c. Place bed in the reverse Trendelenburg position d. Encourage bed rest until analgesic takes effect. 44. A 9 years old female client recently diagnosed with diabetes mellitus. Which symptoms will her parents most likely report? a. Voids only one or two times per day b. Drinks more soft drinks than previously c. Refuses to eat her favorite meals at home d. Gained 10 pounds within one month 45. A gravida 3 para 3 who is Rh negative delivers a full infant at home with assistance of a nurse midwife. Two days later, the client calls the clinic to ask if it is necessary to see the health care provider since the infant is healthy, and she is not having any complications. The woman’s history indicates that both previously born infants were Rh-negative. a. The newborn’s blood type should be tested to determine the need for RhoGAM b. It is likely that the husband is Rh-negative, and if so RhoGam c. RhoGam injections must be administered within 24 hours after delivery d. RhoGam is not indicated since both previous babies were Rh- negative 46. A visitor in the emergency department report to the secretary that there is a bag outside the bathroom. When the unit secretary reports this to the nurse, what action should the nurse take? a. Ask the ward secretary to see if the bag contains clothing b. Personally, retrieve the bags and access the contents of the bag c. Tell housekeeping supervisor to put the bag and lost and found d. Direct the until secretary to notify the hospital security officer 47. The charge is making assignments on an in-patient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignment is best to assign to the PN? a. Routine morning vital signs and weights b. Administration of routine medication c. One- on One observation of a suicidal client d. Detoxification precaution check list 48. The nurse receives an evening shift report for a client who is scheduled for electroconvulsive therapy (ECT) in the morning. Which medication may the nurse is required to withhold this evening? a. A bronchodilator. b. An antihypertensive. c. An antacid. d. A benzodiazepine. 49. The nurse note that influenza immunization rates much lower for certain demographic groups than for others. Which intervention is likely useful in increasing the rates of immunization in these under- served immunization groups? a. Reports describing influenza rates during times of greatest b. Radio announcements about the availability of the influence vaccine c. Designation of clinics conveniently located in target neighborhoods d. Legislative proposals that mandate influenza vaccination for all 50. The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client a. With pneumonia with the serum potassium is 6.5 mmg b. With atrial fibrillation whose saline lock is infiltrated. c. Who is receiving a heparin infusion and has developed hematuria. d. Whit hypertension whose blood pressure is 230/118 51. In conducting a pain assessment of a client with osteoarthritis, what action should the nurse include? a. Observe client during movement of affected joints. b. Ask if pain lessens with elevation or the extremity. c. Measure vital sign changes after physical activity. d. Collet dietary history of calcium-rich food intake. 52. Which approach should the nurse use when providing care for a client who has a stroke in the Boca’s area of the left cerebral cortex? a. Recognize that the words spoken may not make sense b. Re identify personal care articles as the client uses them c. Listen patiently and allow extra time for expression d. Speak slowly and use simple words and short phrases 53. A young male client is admitted to rehabilitation following a right above- Knee (AK) amputation for a severe traumatic injury. He is in the commons room and anxiously calls out the nurse, stating that his “right foot is aching”. The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? a. Offer assist the client to a quieter location so he can relax b. Administer a prescription for gabapentin, a neuroleptic agent c. Teach the client how to wrap the stump with an elastic bandage d. Encourage discussion of feelings about the loss of his limb 54. A client is a discussing feeling related to a recent loss with her nurse. The nurse remains silent when the client says, “I don’t know I will go on”. What is the most likely reason for the nurse’s behavior? a. The nurse is respecting the client’s loss b. Silence allows the client to reflect on what was said c. Silence reflecting the client sadness d. The nurse is stating disapproval of the statement 55. A male client with AIDS and Pneumocystis carinii pneumonia has a 4+ T cell count of 200 cells/ microliter. He asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client’s question? a. Exposure to multiple environmental infectious agents overburdens the immune system until fails b. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages c. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organism d. The humoral immune response lacks B cells that form antibodies and opportunistic infections result 56. The nurse is imitating a 500 ml IV of a normal saline at 60 ml/hour for a client with. How many hours should the IV infuse? Enter numeric value only. If rounding is required round to the nearest tenth). 8.3 57. The camp nurse is teaching adolescents about the prevention of tinea pedis. Which instruction should the nurse include in the teaching plan? a. Wear water shoes in the public shower b. Avoid using cosmetics that block sebaceous glands c. Use moisturizing creams to retain skin moisture d. Do not share a brush or comb with anyone 58. A client in labor state, “I think my water just broke” The nurse notes the umbilical cord is on the perineum. What action should the nurse perform first? a. Place the client in Trendelenburg b. Administer a fluid bolus of 500 ml c. Administer oxygen via face mask d. Notify the operating room team 59. A young male with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take? a. Initiate an ethics committee review of the case b. Ensure resuscitation equipment is available c. Place a DNR bracelet on the client’s arm d. Ask the family to review options with the client 60. A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collated by the admitting nurse, is particularly helpful in planning care for this child? a. Reactions to any previous hospitalizations. b. List of achievements timeline for developmental milestone. c. A history of rubella, rubeola, or chicken pox. d. Mother’s use of alcohol, drugs or cigarrete during pregnancy. 61. A 60 years old female client ask the nurse about hormone replacement therapy (HRT) as means of preventing osteoporosis. Which factor in the client’s history is a possible contraindication for use el HRT? a. She had problems with “hot flashes” several years ago b. Her 60 years old sister has Alzheimer’s disease c. She is taking medication for high blood pressure d. Her mother and sister have a history of breast cancer 62. A client with a history of heroin and alcohol abuse is admitted for treatment of cellulitis from a puncture wound. The client is flushed diaphoretic, and slow to respond to verbal stimuli. Vital signs are temperature 1010 F (38.30 C), heart rate 124 beat/minute, respirations 26 breaths/ minute, and blood pressure 88/24 mmHg. Which intervention should the nurse implement first? a. Monitor for drug withdrawal b. Establish intravenous access c. Obtain venous blood cultures d. Give prescribe antiemetic 63. The nurse provides teaching about home peritoneal dialysis to a client preparing for discharge. Which comment by the client reflects that correct learning has occurred? a. Fluid may be warmed in a microwave prior to instillation to reduce discomfort. b. Returned dialysate volume that is greater than amount instilled should be reported. c. Intra-abdominal pressure is reduced by standing during indwell and outflow phases. d. Dialysate fluid that returns cloudy or opaque should be reported to the clinic. 64. When identified the goals to be included in a client’s plan of care, the nurse should take which action a. Review the priority nursing diagnosis included in the plan of care b. Compare the client’s manifestations with the defining criteria of related problems c. Ensure that all treatment prescribe by the health care provider have been initiated d. List the nursing actions that need to be implemented most immediately 65. A client with hematuria secondary to urinary tract infection has a prescription for IV administration of the cephalosporin cefoperzone. What action should the nurse Implement? a. Monitor the client’s PT? INR before administering the dose b. Hold the schedule dose and consult with the health care provider c. Access the client blood pressure before and after the dose d. Administer the prescribed dose of medication as schedule 66. A client who is hemorrhaging from severe leg injuries receives 430 ml of whole blood before being taken to the operating room for emergency surgery. Which nursing intervention is most important for the nurse to complete after the transfusion is infused and before surgery begins? a. Obtain partial thromboplastic time b. Asses breath sounds for crackles c. Monitor bilateral peripheral pulses d. Determine the red blood cell count 67. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Complete abstain from heroin or cocaine use b. Admit to others that he is a substance abuser c. Remain alcohol free for 12 hours prior to the first dose d. Attend monthly meetings of alcoholics anonymous 68. A client experiences residual effects following acute attacks, of Meniere’s disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective? a. Oxygen saturation level of 99% b. Ambulates easily without vertigo c. Blood pressure of 120/80 mmHg d. Headaches rated at 0on 0-10 scale 69. What diet should the nurse recommend for a client who is in acute renal failure? a. High protein, low carbohydrate, low sodium, high potassium b. Low protein, high carbohydrate, low sodium, high potassium c. High protein, low carbohydrate, low sodium, low potassium d. Low protein, high carbohydrate, low sodium, low potassium 70. An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Improved level of consciousness b. Decrease abdominal girth c. Clear, dark amber colored urine d. Prothrombin time within normal limits 71. A client with a history of heart failure presents to the clinic with a nausea, yellow vision, and palpitations. Which finding is most important for the nurse to assess in the client? a. Ask client about exposure to environmental heat b. Obtain a list of medication taken for cardiac history c. Determine the client’s level of orientation and cognition d. Asses distal pulses and signs of peripheral edema 72. A home health nurse is reviewing the laboratory results for several clients with a history of heart failure (HF). Which client finding should the nurse report to the healthcare provider. a. B-type natriuretic peptide 550 pg./mg b. Glycosylated hemoglobin of 7% c. Total cholesterol 190 mg/dl d. Potassium 3.7 mEq/L 73. Dobutamine 4mcg/kg/minutes is prescribed for a client who weighs 165 pounds. The 1.000 mg of dobutamine solution is dispensed in 250 ml of D5 w. How many ml/hours should the nurse program the infusion pump? (Enter the numeric value only. If round is required, round to the nearest tenth) A: 4.5 74. The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take? a. Maintain the current IV antibiotic schedule b. Schedule a portable chest x-ray per PRN protocol c. Milk the tube to remove any clots d. Obtain a specimen of the drainage for culture. 75. The healthcare provider prescribes Cytovene (Ganciclovir) 375 mg q12 hour to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 ml iv bag. How many drops/minute should the nurse regulate the gravity infusion using a drip chamber that delivers 10 drops/ml? > 17. 76. Which intervention should the nurse include in the best teaching plan a client with pruritus? a. Encourage the client to keep a warm sleeping environment b. Discourage the use of any type of skin lubricant c. Instruct the client to keep fingernails trimmed short c. Explain the importance of not taking any type of tub bath 77. An adult woman, who returns to the telemetry unit following cardiac catheterization, has an infusion with a secondary solution of nitroglycerin. She is restless while lying flat and is complaining of a throbbing headache. Which intervention should the nurse implement? a. Obtain an orthostatic blood pressure b. Immobilize the affected extremity c. Pause the nitroglycerin infusion d. Raise the head of bed 30 degrees 78. Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an Iv infusion pump? a. Magnesium in Normal Saline prescribed for hypomagnesemia b. Regular insulin in Normal Saline prescribed for ketoacidosis c. Heparin in Normal saline prescribed for deep vein thrombosis d. Ceftriaxone in 5% dextrose in water prescribed for pneumonia 79. A male client with a chronic illness is told that he has a prognosis of three months to live. When the home health nurse visits him at his assisted living apartment where he lives his wife, he states that he still feels strong and does not have any pain, but he tells the nurse that a neighbor has advised him to consider hospice care. What action should the nurse take? a. Arrange for a hospice representative to visit the couple to explain the services a hospice provides. b. Complete an assessment to determine if the client and his spouse have accepted the prognosis c. Suggest that the couple wait until he develops symptoms that require care by a hospice team. d. Determine if the client is ready to move to a facility where hospice services can be provided 80. The high pressure alarm on a mechanical ventilator is sounding. What intervention should the nurse implement immediately? a. Verify that all ventilator tubing is connected to the endotracheal tube b. Asses mental status for impact of sedation on respiratory depression c. Check for leaks in the tubing connecting the endotracheal tube to the ventilator d. Auscultate bilateral for breath sounds the perform endotracheal suctioning 81. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is and the UAP is placing soft pillows along the side rails. What action should the nurse implement? a. Ensure that the UAP has placed the pillows effectively to protect the client b. Ask the UAP to use some of the pillows to prop the client in a side lying position c. Assume responsibility for placing the pillows while the UAP completes another task d. Instruct the UAP obtain soft blankets to secure to the side rails instead pillows. 82. The nurse is admitting women who have an arteriovenous (AV) fistula in her right arm that is use for hemodialysis. She missed her last hemodialysis session and is experiencing shortness of breath and irregular heartbeat. Which action should the nurse assign to the unlicensed assistive personnel (UAP) who is working with the nurse? a. Measure vital signs b. Obtain body weight per bed scale c. Notify dialysis unit of admission d. Check for fistula bruit 83. When is the best time for the nurse to assess a client for residual urine? a. When the client’s bladder is distended b. After draining the urinary catheter bag c. Just prior to the client voiding d. Immediately after the client voids 84. A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next? a. temperature b. Blood pressure c. Oxygen saturation d. Capillary glucose 86. A client with an electrical injury is admitted for observation. The client has a small entrance site on the left hand and an exit site on the left foot. Which intervention is most important for the murse to include in the client’s plan of care? a. Check for changes in level of consciousness periodically. b. Perform passive range of motion exercises frequently. c. Monitor cardiac function continuously. d. Assess lungs sounds hourly. 87. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? a. At least I hit the wall instead of hitting the psychiatric aide. b. I want to be here because I know it is the best psychiatric facility. c. I am here because the police thought I was doing something wrong. d. Don’t believe everything my family tells you, I am not crazy’ 88. Vaginal examination reveals that a laboring client’s cervix is dilated to 2 cm, 70% effaced, with the presenting at -2 stations. The client tells the nurse, “I need my epidural now! This hurts” The nurse response to the client should be based on what information? a. The baby needs to be at zero station before an epidural can be administered. b. The client should be dilated at least 8 cm before receiving an epidural c. Administering an epidural at this point would slow the labor process c. The client will need to be catheterized before the epidural can be administered. 89. While changing the abdominal dressing of a client who had surgery three days ago, the nurse identifies a yellow drainage from separations in the incision line. After cleaning the wound with normal saline, what action should the nurse implement? a. Cover with a sterile non-adherent dressing b. Place a transparent dressing over the wound c. Leave the incision open to air. d. Apply a dry sterile dressing. 90. Following a traumatic delivery an infant receives an initial Apgar score of 3. What intervention is most important for the nurse implement? a. Repeat the Apgar assessment in 5 minutes b. Page the pediatrician STAT c. Continue resuscitative effort d. Inform the parent of the infant’s condition 91. A female client who is admitted with ketoacidosis (DKA) is demonstrating Kussmaul’s breathing and has severe headache along with nausea. Her arterial blood gases (ABG) are: Ph: 750; PaCO2 30 mmHg; HCO3 24mEq/L. Which assessment finding warrants immediate intervention by the nurse? a. Fruit breath b. Muscle stiffness c. Abdominal pain d. Mental stupor 92. A 9-year-old with celiac disease is admitted to the pediatric unit following An appendectomy. Which food should the nurse remove from this child’s meal tray? a. Turkey b. Fruit cup c. Crackers d. Chicken rice soup 93. A female client has been in asystole for twenty minutes. She was intubated and …epinephirine(Adrenalin) 1 mg and atropine sulfate 1mg IV. There has been no change in the rhythm. Which intervention should the nurse implement? a. Assist with placement of a transcutaneous to restore rhythm. b. Arrange a private area to discuss with family desires for continued life-support. c. Administer another dose of atropine sulfate 1 mg q5 minutes for 30 minutes. d. Continue CPR and shock at 360 joules q10 minutes for 30 minutes. 94. A male adolescent was admitted to the unit two days ago for depression. When the mental nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. a. Plan to talk with the client the next day b. Report the behavior to the next shift c. Offer to play a game of cards with the client d. Document the behavior in the chart 95. A 4-year old child, admitted to the emergency department in shock following a motor vehicle collision, lacks venous access, and a intraosseous needle…. a. Initial resistance to flushing the needle occurs b. Fluid is administering freely with no soft tissue swelling. c. Pulsatile blood flow is present in the needle hub d. The needle shaft can be moved easily in all directions. 96. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included when preparing the client for this treatment? a. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider. b. Describe the sign of goiter because this is a common side effect of radioactive iodine. c. Explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately. d. Explain the need for using lead shields for 2 to 3 weeks after the treatment 97. An 85-year-old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel a. The resident needs to know the rules concerning unwanted touching b. This is sexual harassment and needs to be reported to the administration immediately c. The UAP needs to be reassigned to another group of residents, preferably females only. d. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need. 98.Two days after undergoing a craniotomy for a brain tumor, hourly intake and output records indicate that for the last 2 hours the client has had a large amount of dilute urine output. The nurse obtains a blood glucose level and urine specific gravity. Which assessment findings indicate that the client is experiencing diabetes insipidus? (Select all that apply) a. Urine output 600ml/hour b. Complaint of extreme thirst c. Blood glucose 500 mg/dl d. Specific gravity 1.01. Grams/ml e. Positive urine ketones 99.The nurse is reviewing the results of arterial blood gases for a client who is admitted with diabetic ketoacidosis Ninguna de ellas a. ph 7.34, pco2 32mmHg, HCO3 24 mEq/L b. ph 7.48, pco2 36 mmHg, HCO3 29 mEq/L c. ph 7.46, pco2 30mmHg, HCO3 20 mEq/L d. ph 7.24, pco2 47mmHg, HCO3 19 mEq/L 100.During a prenatal visit, a client at 30-weeks’ gestation reports persistent heartburn a. instruct the client to take an antacid as needed b. ask if blurred vision and headache have occurred. c. explain that heartburn is a common discomfort. d. check urine for presence of glucose and ketones. 101. The public health nurse is called to investigate a report of several cases of chickenpox (varicella virus) at day care center. The day care worker states that five children have been sent home over the past two weeks with fever and itchy blisters? a. Validate that the children sent home did develop chickenpox b. Confirm the number of children with symptoms c. Determine how many people have been exposed d. Report the presence of a viral endemic at the day care center 102. The charge nurse is making assignment for 15 bed skilled nursing units for two LPNs, and two UAPs. Which client should be assigned to the RN? a. Has right hemiplegia as the result of the CVA and receives continuous gastrostomy feeding for enteral pump b. Has pneumonia following a total knee replacement and is receiving clarithromycin (Biaxin) PO c. Is in end stage Alzheimer’s who requires feeding and is waiting for long term facility placement. d. Had bilateral above knee amputation now has a sacral decision skin flap and receiving vancomycin IV 103. The healthcare provider prescribes digoxin (Lanoxin) elixir 125mcg PO. The drug is available in a 60 ml bottle labeled. “Digoxin (Lanoxin) elixir 0.05 mg/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) 3 ML 104. He nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. completely abstain from heroin or cocaine use b. admit to others that he is a substance abuser c. remain alcohol free for 12 hours prior to the first dose d. attend monthly meetings of alcoholics anonymous. 106. An adult female with a history of type diabetes mellitus (DM) a. portable chest x-rays. b. serum electrolytes and lactate levels c. ondansetron 4mg IV q3 hours d. hourly urine output. 107. A young adult male who is admitted for multi-substance abuse tell the nurse that he has been arrested for assault of a police officer, contributing to the delinquency of a minor, possession of marijuana, and public intoxication. Based on this history, which intervention should the nurse include in this client’s plan of care? a. Encourage the client to make decision about his daily care b. Establish trust overcome the client’s suspiciousness c. Provide consistent confrontation of manipulative behavior d. Recognize the client for any positive behaviors he exhibits 108. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD). Which approach should the nurse use? a. Obtain arterial blood gases (ABGs) prior b. Perform the drainage immediately after meals c. Instruct the client to breathe shallow and fast a. Explain that the client may be placed in five positions 109. Penicillin G procaine (Bicillin C –R) 240.000units IM is prescribed for a 4 years old child who has a streptococcal respiration infection. The medication vial is labeled 1.200.000 units/2ml. How many ml should the nurse administer (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.4 110. A healthcare worker with no known exposure to tuberculosis has received b. refer client to a healthcare provider for isoniazid therapy c. document negative results in the client’s medical record. d. instruct the client to return for a repeat test in 1 week. e. review client’s history for possible exposure 111. The home health aide caring for a homebound hospice calls to inform the nurse the client has reported feeling constipated. What task should the nurse instruct the health aide to perform? a. Teach the client about foods high in fiber b. Administer a prescribed dose of laxative c. Listen for the presence of bowel sounds d. Assist the client to drink warm prune juice 113. A client who received an aortobifemoral bypass is admitted to the intensive care unit with one large bore IV a right radial arterial line. Which intervention is most important for the nurse to implement? a. Insert a second large bore intravenous (IV) site b. Compare manual and arterial line blood pressure c. Asses bilateral distal peripheral circulation hourly c. Monitor urinary output and renal function test 114. The mother of two toddlers who was recently divorced is scheduled for a breast augmentation. During the day surgery admission process, the client tells the nurse that she has not executed a legal will…. a. Explain the benefit of executing an advanced directive. b. Flag the client’s record with “do not resuscitate”. c. Determine if the client’s ex-husband knows her wishes regarding life-support. d. Encourage the client to execute a will that identifies a guardian for her children. e. Document the client’s statement on the admission form. 115. When conducting discharge teaching for a client who has had a mechanical valve replacement, What information should the nurse plan to include? a. Heparin injection will be required to decrease the incidence of clot formation. b. the client will need to take an antibiotic before dental procedures. c. it will no longer be necessary to take daily doses of anticoagulants. d. Mechanical valves usually must be replaced within 7 to 10 years after insertion. 116. The nurse learns that a male client not know the purpose the antipsychotic medication ziprasidone (Geodon) that he is taking. How can nurse best explain the purpose of this medication? a. “An antipsychotic medication promotes socialization” b. “This is an antipsychotic medication to calm you down” c. “This medication helps people with schizophrenia” d. “This medication will help you think more clearly” 117. A client who participates in a health maintenance organization (HMO) needs a bone narrow transplant for treatment of breast cancer a. have the client’s healthcare provider writes a letter to the HMO explaining the need for the transplant. b. encourage the client to call a lawyer so that a lawsuit can be field against the HMO if necessary. c. help the client place a call to the HMO to seek information about limitations of coverage. d. Have the social worker call the state board of insurance to register a complaint against the HMO. 118. Which location should the nurse place the stethoscope to auscultate bronchial breath sound?(click on the correct location. To change on a new location). La segunda linea, bronchial 119. Four hours following of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first? a. Elevate the client’s right hand on one or two pillows b. Complete a neurovascular assessment of the right hand c. Measure the client’s blood pressure and apical pulse rate d. Notify the healthcare provider of the finding immediately 120. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. One hour later the client tells the nurse that his first specimen is in the urinal. Which action should the nurse take? a- assess the client for confusion and reteach the procedure. b- empty the urinal contents into the 24-hour collection container. c- discard the contents of the urinal. d- check the urine for color and texture 121. The school nurse observes a 5-year-old boy limping with limited movement of his right leg. The child denies injury to the leg. Which intervention should the nurse implement? a- teach the child lower extremity stretching exercises. b- apply warm, moist compresses to the affected limb. c- notify the parents to take the child to see a healthcare provider. d- encourage the parent to obtain shoes that provide arch support. 127. A client with draining skin lesions of the lower extremity is admitted with possible Methicillin. Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply). a. End wound drainage for culture and sensitive b. Use standard precaution and wear a mask c. Monitor the client’s white blood cell count d. Institute contact precaution for staff and visitors e. Explains the purpose a low bacteria diet 128. A 3 years old with HIV infection is staying with a foster family who is caring for three other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse she should do. Which action should the nurse take first? a- Review immunization records of the child with an HIV infection b- Place the child with an HIV in a protective environment c- Report the exposure of the child with HIV to the Health Department d- Remove the child with an HIV infection from the foster home 129. A male client with iron deficiency anemia tells the home care nurse that he plans to take his oral iron supplement with a glass of orange juice every day. How should the nurse respond? a- confirm that Vitamin C improve iron absorption b- remind the client to avoid the use of aspirin products. c- recommend a weekly vitamin c supplement instead d- suggest taking the supplement with a dairy product. 130. Several experienced registered nurses are serving on a screening committee to interview prospective candidates for a nurse-manager position on an acute care inpatient unit. The candidate with which characteristic is probably best for this position? a- only child in family; master degree in nursing with nurse practitioner certification; ran track in college. b- middle child in family; associate degree in nursing; class treasurer in high school. c- oldest child in family; bachelor degree in nursing; played on the college volleyball team. d- youngest child in family; diploma in nursing and certification in nursing; member of ANA. 131. The nurse stops to render aid at the scene of a motor vehicle collision and finds a child about 6 months of age strapped into a car seat in the back seat of the car. After calming the infant with a pacifier, what action should the nurse take? a) Remove the infant from the car seat while stabilizing the neck. b) Assess the infant’s ability to move arms and legs. c) Determine if pupils constrict when exposed to light. d) Lift the car seat out of the car with the infant strapped in it. 132. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was a month ago, and she has not yet received any medical care. She smokes but denies any other substance use. What intervention(S) should the nurse implement? (Select all that apply) a- Offer nutritional instruction b- Arrange for childcare c- Encourage smoking cessation. d- Notify her parent e- Refer for prenatal care. f- teach breastfeeding methods 133. Discharge teaching for the client with a permanent pacemaker insertion includes as a goal that the client is able to identify the signs of pacemaker failure. Which client statement indicates that the goal has been met? a- I should be able to describe the type and serial number of my pacemaker. b- I should seek medical attention for pulse changes or dizziness. c- I need to know how the pacemaker rate is change d- I need to report any redness at the insertion site to my healthcare provider. 134. The mental health unit nurse completes the admission assessment for a depressed adolescent female with suicidal ideation. The client reports that she became angry with her sister, so she took a handful of pills. What goal is most important for the nurse to establish with this client? a- interact positively with the staff on the unit. b- verbally express her anger toward her family c- Attend at least 2 group sessions daily on the unit d- Identify three effective ways to cope with feelings. 135. A client has a new prescription for the maximum recommended dosage of piperacilin/tazobactan (Zosyn) for nosocomial pneumonia. The nurse should laboratory finding to the healthcare provider administering the prescription a. Decreased creatinine clearance b. Elevated white blood cell count c. Elevated cholesterol and lipoproteins d. Presence of gram positive bacteria in the sputum 137 While interviewing an elderly client, the nurse observes that the client’s hands tremble uncontrollably while reaching for a glass of water. a. Transient ischemic attack b. Sensory dysfunction c. Muscle flaccidity d. Intention tremor 138. After administering varicella vaccine to a five-year-old child, which instruction should the nurse provide the child’s parent? a- apply a cool pack to the injection site to reduce discomfort. b- Any level of fever is serious and should be reported right away. c- Chewable children’ aspirin will help prevent inflammation. d- Keep the child home from daycare for the next two days. 139. A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow- up by the nurse? a. CT scan that was performed dix months earlier b. Takes metformin ( Glucophage ) for type 2 diabetes mellitus c. Report of client’s sobriety for the last five years d. Metal hip prosthesis was place twenty years ago 141. Which nursing assessment is the priority when caring for a client with acute adrenocortical insufficiency? a. Determining fail risk b.Monitoring blood pressure c. Noting areas of skin breakdown d. Evaluating mood and behavioral changes 142. A male client arrives in the Emergency Department (ED) with a deep, full- thickness burn over the anterior surface of both upper legs. Which priority intervention should the nurse implement? a. Give IV analgesia b. Administer tetanus immunization c. Start IV antibiotics d. Give an IV bolus of normal saline 143. Three days following a bowel resection, an adult woman reports shortness of breath and chest pain. The client’s oxygen saturation is 87% while receiving 100% oxygen per non- rebreather mask. Which intervention should the nurse implement? a. Prepare to insert a nasogastric tube to intermittent suction b. Obtain airway management equipment for oral intubation c. Administer a prescribed anticoagulant immediately d. Remove the surgical dressing to observe the incision 144. The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? a) A young man with schizophrenia who wants to stop taking his medication b) The mother of a child who was involved in a physical fight at school today. c) A client diagnosed with depression who is experiencing sexual dysfunction. d) A family member of a client with dementia who has been missing for five hours 145. The nurse working in a disaster area assesses an adult male who has partial- thickness burns on his lower legs, or approximately 10% of his lower body. Which color of triage tag should the nurse place on this client? a- Black b- Green c- Yellow d- Red 146. The nurse should anticipate difficulty visualizing the point of maximal impulse (PMI) in which client? a- A 75-year-old with a pneumothorax and a chest tube. b- A 2- year old who is demonstrating diaphragmatic breathing. c- A 54- year old who is 5 feet tall and weighs 300 pounds. d- A 45- year old long distance runner with a BMI of 18. 147. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client exhibit? a- hypotension and venous pooling in the extremities. b- complaints of chest pain and shortness of breath. c- profuse diaphoresis and severe, pounding headache. d- pain and burning sensation upon urination and hematuria. 148. An older adult who has a shuffling, unsteady gait wants to ambulate in the hallway to a family visitation room. To reduce risk I jury, which action should the nurse take before the client leaves the room? (Select all that). a- Review the client’s vital signs and activity tolerance b- Assist the client in applying smooth soled shoes c- Confirm that the hallway floors are clean and dry d- Place a mat on the floor where the client can stop and rest e- Remove carts or other obstacles from the client’s pathway 149. A client with hematuria secondary to a urinary tract infection has a prescription for IV administration of the cephalosporin cefoperazone. What action should the nurse Implement? a- Monitor the client’s PT? INR before administering the dose b- Hold the schedule dose and consult with the health care provider c- Access the client blood pressure before and after the dose d- Administer the prescribed dose of medication as schedule 150. The home health nurse observes an older female client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. What action should the nurse take? a- Instruct the client to use the arms of the chair for support. b- Apply gait belt to assist the client as she rises out of the chair. c- Encourage client to use the walker leg with the walker when rising. d- Hold the walker securely to prevent slipping when the client rises. 151. An adolescent with major depression disorder has been taking duloxetine (Cymbalta) 12 days. Which assessment finding requires immediate follow-up a. Exhibits an increase in sweating b. Describers life as without purpose b. States often fatigued and drowsy c. Complains of nausea and loss appetite 152. The nurse is teaching a new mother about breastfeeding. The client tell the nurse that her sister became very uncomfortable when she tried to breastfeed because she had too much milk. What suggestion should the nurse provide to help this client deal with the discomfort associated with engorged breast? a- Wear a supportive bra at all times b- Use breast cream to help prevent discomfort c- Take two acetaminophen (Tylenol) to relieve the discomfort d- Put a heating pad on the breast while they are engorged 154. The nurse plan to encourage a group of young adult clients to engage in problem solving strategies. Which action is most useful for the nurse to include during the teaching session? a- Incorporate verbal analogies b- Offer positive reinforcement c- Provide physical demonstrations d- Use simulation activities 155. A client who receives multiple anthyhypertensive medication experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? a- Increased urinary clearance of the multiple medication has produced diuresis and lowered the blood pressure. b- The additive effect of multiple medication has caused the blood pressure to drop too low c- The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension. d- The antagonistic interaction among the various blood pressure medication has reduced their effectiveness 156. When conducting a physical examination, the nurse is assessing a client’s abdomen and …a centrally localized distention that is pulsating. This finding should direct the nurse to consider what pathology? a- Tympany b- Hernia c- Aneurysm d- Appendicitis 157. The emergency room is alerted that a child is arriving by ambulance with history of flu-like symptoms for the past week. The reported vital sing is temperature 101 F, heart rate 168 beats/minutes, and blood pressure 90/60. The child is lethargic with a capillary refill time 4 seconds. When preparing for the child’s arrival, the nurse should assemble which equipment? a- Mechanical ventilator. b- IV infusion pump c- Cooling blanked d- Automatic defibrillator. 158. A 3-yeard-old with HIV infection is staying with a foster family who is caring for three other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first? a- Review immunization records of the child with an HIV infection. b- Place the child with an HIV infection in a protective environment. c- Report the exposure of the child with HIV to the Health Department. d- Remove the child with HIV infection from the foster home. 160. The nurse working in a community health clinic is providing discharge instructions for a client diagnosed with allergic rhinitis. Which discharge instructs should the nurse discuss with this client? a. Discourage nose blowing prior to administering nasal medication b. Explain the importance of using nasal saline at least four times a day c. Encourage the client to wear a hat when experiencing prolonged sun exposure e- Stress the importance of carrying epinephrine at all times when outside 161. When using a Yankauer oral- tip catheter to suction a client’s oropharynx, which action should the nurse take before inserting the catheter into the oropharynx? a- Ask the client to begin swallowing b- Assess the nares for a deviated septum c- Turn on the continuous suction device d- Apply suction by occluding the port 162. A client diagnosed with primary open-angle glaucoma received a prescription for Miotics-eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include to this client’s teaching? a) “Wash your hands after each administration of eye drops.” b) “Squeeze your eye closed after administering the drops.” c) “Administer the medication directly on the cornea.” d) “Do not allow the dropper bottle to touch the eye.” 163. What assessment finding places a client at risk for problems associated with impaired skin integrity? a- Absence of skin tenting. b- Capillary refill 5 seconds. c- Smooth nail texture. d- Scattered macula on the face. 164. The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in theses underserved immunization groups? a- Radio announcements about the availability of the influenza vaccine. b- Reports describing influenza rates during times of greatest prevalence. c- Legislative proposal that mandate influenza vaccinations for all. d- Designation of clinics conveniently located in target neighborhoods. 165. An older male client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargy, moderately comfort and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? a. Start an intravenous infusion of normal saline b. Administer the client’s usual dose of insulin c. Obtain a serum potassium level d. Assess pupillary response to light 166. When assessing a client’s pain, the nurse first determines the location and intensity of the pain. To gather data about the quality of the pain, what action should the nurse take? a. Ask the client to describe the pain experienced b. Gently palpate the area and observe the response c. Provide the client with a visual analog scale d. Instruct the client in use of a numeric pain scale 167. A terminally ill male hospice client who is a home is showing decreased awareness of his surroundings His appetites is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out the hospice nurse implement? a. Instruct family to offer client only soft bland foods b. Encourage family to speak often with the client c. Ask family to remain nearby, but in another room d. Teach family how to assist the client a wheelchair 168. The nurse is assessing a client with an elevated serum bilirubin level. Which actions should the nurse include in the assessment in response to this finding? (select all that apply) a. Assess for flushing of the face and neck b. checks the color of the sclerae c. Monitor for cyanosis of mucus membranes d. notes any changes in urine color or appearance e. observes the skin for scratch marks due to pruritus 169. Two days’ admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply) a- Document the statement in the nurse’s notes. b- Notify the food services department of the allergy. c- Note the allergy on the diet intake flow sheet. d- Enter the allergy information in the client’s record. e- Add egg allergy to the client’s allergy arm band. 170. A client is receiving a continuous infusion normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and headache. Urine output is 800 ml over the past 24 hours with a central venous pressure of 15 mmHg. The nurse notes respiratory crackles and bounding central pulses. Vital signs temperature 101.2 degrees F (38.4 degrees C). Heart rate 96 beats/ minute, respirations 24 breaths/minute, and blood pressure of 160/90. Which intervention should the nurse implement first? a. Review last administration of IV medication b. Administer PRN dose of acetaminophen (Tylenol) c. Decrease IV fluids to keep vein open (KVO) rate d. Calculate total intake and output for last 24 hours 171. Following a lumbar puncture, a client voices several complaints. Which complaint indicates to the nurse that client is experiencing a complication of the procedure? a. “My throat hurts badly when I swallow and when I talk” b. “ I have headaches that gets worse when I sit up” c. “I am having pain in my lower back when I move my legs” d. “ I feel sick to my stomach and am going to throw up” 172. A female client who is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? a. Notify healthcare provider of client’s respiratory status b. Ask the client to discuss “do not resuscitate” with her healthcare provider c. Provide supplemental oxygen per venture mask at 24% concentration d. Allow the client’s family to stay at the client’s bedside 173. While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding percussion of the abdomen should the nurse document indicating hepatomegaly? a- Areas of tympany within the liver region. b- Tympany noted boarding the margins of the liver. c- A dull percussion tone outside the costal margins. d- A hollow sound over the lower abdomen. 174. What information should the nurse include when giving discharge instruction a left eye cataract extraction with extraction with lens implant? a- Turn, cough, and deep breath every 2 hours. b- Sleep flat in a supine position. c- Observe pupil response of the right eye. d- Administer a stool softener. 175. Epidural analgesia is prescribed for a client following a total hip replacement. In managing the epidural analgesia, which intervention should the nurse include in the client’s plan of care? a- Assess for sensation in the legs. b- Keep the client flat in bed. c- Assess for capillary refill. d- Change the epidural dressing daily. 176. The nurse observes an older female client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. What action should the nurse take? a. Apply a gait belt to assist the client as she rises out of the chair b. Hold the walker securely to prevent slipping when the client rises c. Instruct the client to use the arms of the chair for support d. Encourage client to use the weaker leg with walker when rising 177. Heparin 5.000 units IV as a loading dose, to be administered over 5 minutes, are prescribed for client with thrombophlebitis. The vital is labeled 10.000units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required round to the nearest tenth) 0.5ml 178. A client has a prescription for 20 units of Novolin 70/30 insulin to be administered subcutaneously. The pharmacy has provided a vial of Novolin N insulin and a vial of Novolin R insulin. What action should the nurse implement? a. Draw 10 units of Novolin R insulin, followed by 10 units of Novolin N into the syringe and administer b. Consult the health care provider about the client’s insulin prescription c. Notify the pharmacy that the incorrect insulin has been delivered to the unit d. Administer a combine dose of 20 units of each of the two types of insulin mixed in on syringe 179. The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client I pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restraint in the wheelchair so that the nurse can change her bed linens. What is the priority by the nurse manager? a. Determine if the client has PRN prescription for an antianxiety agent b. Close the door to the room to avoid disturbing other client in nearby rooms c. Advise the staff nurse to remove the restraints from the client’s wrist d. Contact the healthcare provider to ensure that a prescription for restraints was written 180. A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each food forward. The nurse notes that the client’s elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, what action the nurse implement. a. Explain the need to remove the wheels from the walker b. Demonstrate more coordinated movement of the legs and walker c. Encourage the client to continue using the walker as observed d. Offer to adjust the height of the walker 181. A male client is experiencing leg paint related to the intermittent claudication. Which intervention should the nurse include in the client’s plan of care? a. Wrap elastic bandages around legs b. Measure calf circumference c. Demonstrate use of a cane d. Encourage progressive exercises 182. Following an ileal conduit urinary diversion, a male client voices several complaints. Which finding indicate to the nurse that hi is experiencing complication? a- Amber colored urine coming out of the stoma. b- A bright red, moist ostomy site. c- A dark purplish colored stoma. d- A small amount of bleeding at the stoma site. 183. When assessing an older client, what finding is most indicative of dehydration? a) Skin is warm and dry b) Tenting noted in subclavicular area c) Loss of skin elasticity in the hand d) Thinning hair in the lower extremities 185. A client with c-7 spinal cord injury is experiencing autonomic dysreflexia … first assess the client for which precipitating factor? a) Profuse forehead diaphoresis b) An acutely distended bladder c) A severe pounding headache d) Skeletal traction misalignment 186. The nurse is planning discharge teaching for a client who has cystitis. Which information should the nurse include in the teaching plan? a) Wear cotton underwear b) Use feminine hygiene spray c) Take daily tub baths d) Limit cranberry juice intake 187. A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports he had surgical repair of a recurrent inguinal hernia a week ago and complain of intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first? a. Insert a nasogastric tube (NGT) and attach to low intermittent suction b. Send the client to x-ray for a flat plate of the abdomen c. Give a prescribed analgesic for temperature above 101.00 F d. Place an indwelling urinary catheter and attach a bedside drainage unit 188. A client with eczema is applying 10% urea (Agua Care Cream) onto the affected skin areas. Which finding reflects the expected therapeutic response? a- Reduced pain in eczematous areas. b- Healing with a return to normal skin appearance. c- Decreased weeping of ulcerations in affected areas. d- Hydration of affected dry skin areas. 189. The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding should the nurse identify that are consistent with depression? (select all that apply.) a- Compulsive behavior. b- Poor concentration. c- Sadness. d- Grandiosity. e- Disrupted sleep 190. The nurse finds a fire in the bathroom of an empty client room and immediately reports the location. After reporting the fire, what action should the nurse take next? a- Close the doors to all of the client rooms on the unit. b- Obtain the fire extinguisher located on the unit. c- Shut the doors to the bathroom and empty room. d- Evacuate the clients in the rooms closest to the fire. 191. The healthcare provider prescribes cephalexin (Keflex) 125 mg/5 ml oral suspension for a client who weighs 77 pounds. The recommended safe dose 25 mg /kg/24 hours in 4 divided doses. Based on the client’s weight, how many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.) 9 192. In assessing a 70-year-old female client with Alzheimer’s disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include on this client’s pan of care? a- Notify the healthcare provider of the need for oral antibiotics. b- Ensure that the client get adequate B vitamins in foods or supplements. c- Encourage the client to drink orange juice for added vitamin C d- Scrub the lesions with warm soapy water. 193. An adult male is admitted to the emergency department following a 40-foot fall from the roof of a house. A cervical collar is holding his neck an alignment. He is alert and oriented, and is exhibiting shallow even respirations. A small amount of blood is draining from both ears. A computed tomography (CT) scan is prescribed. Which intervention is most important for the nurse it implement? A. Keep a cervical collar in place. B. Document halo sign around ear drainage. C. Auscultate breath sounds in all lung fields. D. Evaluate pupillary reaction to light 195. As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a- Removing gastric secretions and to relieve abdominal distention. b- Restoring and maintaining a positive fluid balance. c- Reducing hydrochloric acid secretion. d- Decreasing the formation and secretion. 197. A male client is admitted with flash burns to the anterior surface of both arms, anterior trunk, and anterior surface of both legs. Using the rule of nines, what total percentage of the client’s skin surface is burned? (Enter numerical value only. If rounding is required, round to the nearest whole number.) 45 198. A client with uremia is experiencing uremic frost. What action should the nurse implement? a- Explan that hemodialysis is needed. b- Provide frequent skin care and apply lotion. c- Monitor the client’s oral fluid intake. d- Evaluate bony prominences for breakdown. 199. An 8-year-old girl is brought to the clinic by her mother who reports that her daughter has had a severe sore throat for the last three days and suddenly began drooling. The child’s tympanic temperature is 103 F (39.4 C) and she struggling to breathe. What initial action should the nurse should take? a- Review immunization records for influenza vaccine. b- Notify the health care provider immediately. c- Use the tongue blade to inspect the throat. d- Ask the child to cough several times. 200. A 4-year-old is admitted with croup and receives a prescription for a single dose of dexamethasone (decadron) 0.6 mg/kg IM. The child weighs 35 pounds. How many Mg should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.) 10 201. While preparing to obtain a stool specimen for occult blood, the nurse observes that the client’s feces is soft, solid, and light brown. What actio should the nurse implement? a- Wait to obtain the specimen until observable blood is present. b- Contact the healthcare provider before obtain the specimen. c- Obtain the specimen collection from the client’s current bowel movement. d- Withhold specimen collection until tarry black stool is observed. 202. An older adult female client has recently moved in with her daughter who tells the nurse that her mother wakes at 4 am every morning. Further assessment reveals that the older adult is not taking any sleep medications and reports no bladder problems. Which intervention should the nurse implement? C 203. A client with peptic ulcer disease is scheduled to receive doses of pantoprazole (protonic) IV and Sucralfate C 204. The nurse is assigned to care for four clients. After receiving the change of shift report, which client should the nurse assess first? A 205. A postoperative client has a prescription for ketorolac (toradol) 30 mg IV D 206. A client who is admitted to the emergency room following a motorcycle accident A, B, E 207. When explaining dietary guidelines to a client with acute glomerunephritis (AGN), which instruction should the nurse include in dietary teaching? Restrict sodium intake. 208. The mother of a one-month-old infant calls the clinic to report that the back of her infant’s head is flat. How should the nurse respond? a) Position the infant on the stomach occasionally when awake and active b) Prop the infant in a sitting position with a cushion when not sleeping c) Place a small pillow under the infant’s head while lying on the back d) Turning the infant on the left side braced against the crib while sleeping 209. A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine (Intropin). Which intervention should the nurse include in this client’s plan of care? B 210. Legal experts recommend that healthcare institutions take all steps possible to reduce the incrasing incidence and high costs of medical malpractice suits. Which remedy provides the earliest intervention for negligent injuries caused by healthcare providers that might deter legal dispute? B 211. A female client with a pituitary tumor is admitted with dehydration. Her urinary output for the past 24 hours is 7,500 ml and her vital signs are: heart rate 134 beats/minute, blood pressure 90/40 mm Hg, and temperature 102 F (38.9 C). A prescription is received to administer vasopressin. What action should the nurse implement? B 212. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? a) Bagel with jelly and skim milk b) Egg whites, toast, and coffee c) Bran muffin, mixed fruit, and orange juice d) Granola bar and grapefruit juice 213. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? D 214. A client who has a history of uncontrolled hypertension presents with dyspnea, cold moist hands a rapids weak pulse, and jugular vein distention. The nurse initiates oxygen via face mask. Which action should the nurse implement next? D 215. The charge nurse is making client assignments in the intensive care department. The healthcare team consists of one registered nurse (RN) with 10 years’ experience, one RN with 5 years’ experience and a new graduate Rn who just completed a 12-week internship. Which client should the nurse assign to the new graduate RN? B 216. The nurse is preparing an adult with Addison ’s disease for self-management. Which information should the nurse include in the client’s instructions? C 217. A client who was recently discharged after a 40 percent full-thickness burn is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the client’s plan of care for this admission? a- Encourage progressive active range motion. b- Recommend supplemental vitamin D food resources. c- Instruct the client to limit time in direct sunlight d- Teach client how to do muscle strengthening exercises. 218. While planning care for a client experiencing pain, which outcome statement should the nurse include in the plan of care? A 219. The nurse finds a female client crying quietly in her room. What action should the nurse take first? D 220. While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release or the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next? C 221. The RN case-manager working in a home health care agency is making client assignments. Which client should the case manager assign to a newly hired RN with 3 years acute care experience? The client A 222. During a well-baby clinic visit, the mother of a 6-month-old infant asks the nurse if she can have a prescription for poly VI sol with fluoride. Though the infant is still breast feeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain? A 223. The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. B 224. After a client voids, 150 ml of residual urine is measured. Which nursing problem should be included in this client’s plan of care? B 226. Recognizing the role of the role of the kidney in the production of…..with chronic kidney disease (CKD) for what manifestation? No esta complete la pregunta (Si is eritropoyesis de los glóbulos rojos es Pallor, O si es eritrocitos de los glóbulos blancos es jaundice. 227. Prior to obtaining an axillary temperature, the nurse should perform which action? C 228. Accoding to the centers for disease control and prevention which diseases are reportable infectious diseases? ( Select all that apply.) A, B, E 229. The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symtoms are most indicative of progressive hypovolemic shock? B 230. Prior to performing a postpartum assessment, the client tells the nurse, “I have pain in my stitches.”The nurse knows that the client had a mid-line episiotomy. What action should the nurse take first? A 231. Nurse is conducting an assessment and interview of a client who is believed to have Guillain-Barre syndrome.Wich comment by the client has the most significance to this diagnosis? D 232. Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)? D 233. A client’s telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate? B 234. A client with multiple sclerosis has a nursing diagnosis of urinary retention related to sensorimotor deficits. What is the priority nursing intervention when addressing this complication? C 235. The nurse is providing anticipatory guidance for an African-american client who is at 24-weeks gestation. What prenatal laboratory assessment, prescribed at 28-weeks, should the nurse include in client teaching? B 236. A male client who is HIV positive is seen in the clinic for a routine physical examination. He is taking the reverse transcriptase inhibitor medication lamivudine (Epivir). It is most important for the nurse to notify the healthcare provider of which client finding? B 237. The nurse notes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first? D 238. A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay(AFP). What nursing intervention should the nurse implement? D 239. A nurse is administering diazepam, a benzodiazepine; 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply.) B, D, E, 240. A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement? B 241. A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, and restricts joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client? A 242. The healthcare provider prescribes the nonsteroidal anti-inflammatory drug (NSAID)naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow up visit one month later, the client tells the nurse,” The pills don’t seem to be working. They are not helping the pain at all”. Which factor should influence the nurse’s response? B 243. The computerized tomography (CT scan) reveals the presence a dissecting thoracic aneurysm in a client who presented 8 hours ago with intense upper back pain and hypotension. When the client returns from surgery following a thoracic aneurysm repair, the nurse plans to observe for sings of hypovolemia. In assessing for sings hypovolemia,which assessment should the nurse complete first? A 244. A client who admitted to the emergency room following a motorcycle accident is having difficulty breathing. While assessing the client’s chest and lungs, the nurse notes that there are no breath sounds over the left fields. Which actions should the nurse implement? (Select all that apply.) A.B.C 245. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences a) Palpitations and shortness of breath b) Bradycardia and constipation c) Lethargy and lack of appetite d) Muscle cramping and dry, flushed skin 246. A client with heart failure (HF) is receiving an IV infusion of 0.95% normal saline 250 ml at a keep-vein-open (KVO) rate of 40 ml/hour. The IV tubing has a minidrip chamber that delivers 60 micro drops/ml. The nurse should regulate the micro drops gravity IV infusion to deliver how many micro drops/minute? (Enter numeric value only) 40gtt 247. The nurse notes that a newborn at 24 hours of age has large cephalohematoma.What intervention has the highest priority? D 249. A male client with diabetes who normally takes only an oral antidiuretic agent asks the nurse why sliding scale insulin is necessary during his hospitalization for COPD exacerbation and pneumonia. Review of the medication record indicates the client is taking methylprednisolone (solu-Medrol), clindamycin (Cleocin), and pioglitazone (Actos). How should the nurse respond? A 250. An older adult woman had a bowel resection two days ago and has a new colostomy. The nurse preparing the client for discharge. The client has a history of Parkinson disease and will be living with a family member. Which intervention is most important for the nurse to implement? C 251. When assessing a client for risk factors related to hepatitis c, what information is most important for the nurse to obtain from a client who reports a history of multiple blood transfusions? D 252. What explication is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning? C 253. The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased airflow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe? a) Diminished breath sounds b) Low pitched, sonorous rhonchi c) Crackles or course rales d) Pleural friction rub 254. When teaching a client with Parkinson’s disease, which rationale for prescription of carbidopa-levodopa (Sinemet) should the nurse include? A 255. The nurse is planning to use simulation to teach a group of newly hired unlicensed assistive personnel (UAP). In developing the teaching session, what should the nurse do firt? C 256. What instruction should the nurse include n the discharge teaching plan of a client who has started treatment for nearly diagnosed diabetes insipidus (DI)? B 257. While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client’s hand grips. The client reports joint pain and trouble twisting a door knob due to weakness. What action should the nurse take in response to these findings? a) Implement fall precautions to reduce the client’s risk for injury b) Explain that relief of the migraine pain will reduce related symptoms c) Consult with the occupational therapist for a functional assessment d) Gather additional assessment data about the pain and weakness 258. A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the status report provides by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client B 259. A continuous infusion of heparin 10 unit/kg/hour is prescribed for a client with deep vein ANSWER: 15 261. A 78-year-old male client is admitted with complications related to chronic obstructive pulmonary disease B 262. The nurse notes that a client's serum creatinine level is 4.2 mg/dl (371 micromol/L) reporting the finding to the healthcare provider, what additional laboratory value is most important for the nurse to confirm? a) Prothrombin time (PT) b) White blood cell count c) Capillary glucose d) Serum potassium 263. At 20/30, a male client reports that he is unable to go to sleeps due to the pain caused by an infected abdominal incision. Whist intervention should the nurse implement first? A 264. In assessing an adult client with a partial rebreathe mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths/minute. What should the nurse implement? C 265. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? a. Obtain a clean catch mid- stream specimen b. Auscultate for renal bruits c. Begin to strain the client’s urine d. Use a dipstick to measure for urinary ketones 266. The nurse identifies an electrolyte imbalance, an elevated central venous pressure, and generalized edema for a client with full thicknee burns, Which intervention should the nurse implement? B 267. After placing a 36- week gestation newborn in an isolette and drying the infant with several blankets, what should then nurse implement next? a. Place erythromycin ophthalmic ointment in both eye b. Removes the wet blankets and linens from the isolette c. Open the isolettes door to assess the infant’s vital signs d. Administer the vitamin K (Aqua MEPHYTON) injection 268. The nurse assesses an older adult woman’s ability to perform activities of daily living C 269. A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus causes by a chronic skin rash. The client calls the clinic to report increased erythema with purulent exudate at the side. Which action should the nurse implement? a. Schedule an appointment for the client to see the healthcare provider b. Explain that the client needs to complete all prescribed doses of the medication c. Advise the client to apply wrap over the ointment to promote healing d. Instruct the client to continue the ointment until all erythema is relieved 270. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? C 271. A female unlicensed assistive personnel (UAP) is assigned to take vital signs of the client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take? a. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. b. Instruct the UAP that a standard face masks is sufficient for the provision of care for the assigned client. c. Before changing assignments, determine which staff members have fitted particulate filter masks. d. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care. 272. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? a. Offer information about ultrasonography and genotyping to determine sex assignment b. Explain that corrective surgical procedure consist with sex assignment can be delayed c. Support the parents in their decision to assign sex of their child according to their preference d. Discuss the need for cortisol an aldosterone replacement therapy after discharge 274. A female client is admitted to the hospital with a diagnosis of right lower quadrant (RL Q) abdominal pain and a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experience a generalize abdominal aching. Her blood pressure has decrease and her pulse has increased over the past two hours. While waiting for the health care provider to arrive, which intravenous solution is the best for the nurse to initiate? a. Located Ringer’s (LR) at 150 ml/hour b. Normal saline (NS) at 20 ml/hour c. D5w/0.45NS at 125 ml/hour d. Dextrose 10% (D10W) at 83ml/hour 276. A female client engages in repeat checks of doors and windows locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? a. Determine the type and size of the locks b. Ask the client why she checks the locks c. Discuss checking the time frequently d. Plan a list of activities to be carried out daily 278. Onset of big toe joint pain and swelling is diagnosed with gout. Which pathophysiologic process is producing the symptoms of gout? a. Chondrocyte injury destroys joint cartilage, producing osteophytes and joint producing osteophytes. b. An autoimmune inflammation involving IgG response to an antigen causes joint destruction c. Deposition of crystals in the synovial space of the joints produces inflammation and irritation d. An immune complex and autoantibody deposition in connective tissue results inflammation 280. A male client with metastatic cancer rates his pain at 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administer an IV analgesic; the client reports no pain relief. With intervention is most important for the nurse to include in this plan of care? a. Replace transdermal analgesic patches every 72 hours b. Monitor client for break-through pain c. Administer analgesic on a fixed and continuous schedule d. Frequently evaluate the client’s pain 281. A female client with pneumonia and history of sickle cell anemia begins to complain of pain in her fingers, B 282. In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a) Eyelids are matted and crusted b) Oral mucosa is cyanotic c) Face is flushed and diaphoretic d) Cornea are jaundiced 283. An older female client comes to the clinic for a regular check- up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client’s comment, which previous lab values should the nurse compare with today’s report? a. Determine if there a decrease in serum potassium due to renal compromise b. Look for an increase in today’s LDH compared to the previous one to assess for possible liver damage c. Expect to find an increase in today’s APTT as compared to last quarter’s due to bleeding 286. Which assessment data reflects the need for the nurse to include the diagnosis, “Risk for falls” in a client’s plan of care? a. Opioid analgesic received one hour ago b. Recent serum hemoglobin level of 16g/dl c. Expressed feeling of depression d. Stopped posture with a steady gait 287. A client with a C -7 spinal cord injury is experiencing autonomic dysreflexia. The nurse first assesses the client for which precipitating factor? a. Skeletal traction misalignment b. An acutely distended bladder c. Profuse forehead diaphoresis d. A severe pounding headaches 288. The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. The fire is burning my skin away right now” b. The snakes on the wall are going to eat me”. c. The nurse at night is trying to poison me with pills” d. The voices are telling me to kill the next person I see” 289. The mental health nurse observes that a female client with delusional disorders carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust? a- initiates short, frequent contacts with the client. b- Explain that distrust related to feeling anxious. c- Offer to keep the belongings at the nurse’s desk. d- Explain that these beliefs are related to her iliness. 290. When initiating a dopamine (Intropin) intravenous infusion for a hypotensive client, which intervention should the nurse include in the client’s plan of care? a. Perform neuro assessment every 2 hours b. Observe pulmonary capillary wedge pressure (PCWP) c. Assess bilateral breath sounds d. Monitor urinary output every hour 291. A adult male has been hospitalized for the past three weeks due to complications experienced following elective surgery. When the client’s condition first began to deteriorate, his spouse reminder the health care provider that the client has a living will explaining his desire for a natural death. The health care provider does not agree with the client’s living will and refuses to honor it. What action should the nurse take? a. Document healthcare provider’s refusal to honor client’s wishes b. Notify the hospital ethical committee to assist with client’s wishes c. Facilitate a meeting between the health care provider and the spouses d. Have resuscitation equipment readily available 292. A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse to take to assist this client in diminishing his anxiety? a. Reinforce the reality of his financial situation b. Teach him to limit sugar and caffeine intake c. Direct him to drink a glass of red wine at bedtime d. Encourage him to initiate daily rituals. 293. An adult male is transferred from postanesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula B 294. The mother of a child who is hospitalized with croup and is a mist tent brings C 295. Before administering the initial dose of sumatriptan succinate (Imitrex) to a client with a migraine headache, it is most important to determine if the client’s history includes which problem? Coronary artery disease. 296. A 17-year-old male who was arrested a month ago for gang-related B 297. A male client with pernicious anemia takes supplemental folate and self-administers C 298. A one-year-old child with neuroblastoma is crying A 299. During the admission process, a client requests more information about advance directives. Which professional the nurse recommends the client contact? B 300. What self-care outcome is best for the nurse to use in evaluating a client’s recovery from a stroke that resulted in left-sided hemiparesis? D 301. Which pathology occurs with an asthma condition? C 302. A mother brings her 2-month-old infant to the clinic for a well-baby appointment. C 303. The nurse has removed a barbiturate capsule from the unit dose A 304. A registered nurse (RN) practical nurse (PN), and unlicensed assistive personnel (UAP) are working as a team to provide care for an B 305. A client recently diagnosed with Hodgkin’s disease B 306. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? Obtain a “do not resuscitate” (DNR) prescription 307. A terminally ill client has an advance directive that stipulates no resuscitative measures are to be taken. The client’s death is imminent and the family is in the client’s room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood pressure of 60/30. What is the priority nursing action? a) Apply an automatic blood pressure cuff and take readings every 15 minutes b) Elevate the head of the client’s bed and apply oxygen using a face mask c) Teach the client’s family how to use an oral suction device to clear the airway d) Allow privacy for the family and client to express their feelings to one another 308. While adding water to the chest tube drainage system, the nurse knocks over the container causing the blood to spill into the adjacent chamber. Which action should the nurse take? a) Increase suction to 30 cm b) Mark drainage in both chambers c) Assess tubing for fluctuation with respirations d) Replace chest tube drainage system 309. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? a) Cleanse the foot with soap and water and apply an antibiotic ointment b) Provide teaching about the need for a tetanus booster within the next 72 hours. c) have the mother check the child's temperature q4h for the next 24 hours d) transfer the child to the emergency department to receive a gamma globulin injection 310. The nurse is evaluating teaching about drug therapy to treat gout.Which demonstrates an understanding of the use of allopurinol (Zyloprim) a) “I should take this drug when I have gout attacks to reduce symptoms.” b) “The pain and swelling can be controlled by taking this drug every day.” c) “I need to take this drug every day to keep from having any flare-ups.” d) “I need to take the prescribed amount of the drug to get rid of my gout.” 311. A 16-year-old male who has successfully coped with hemophilia for the past 10 years is evaluated by the nurse. As an adolescent, his adjustment to the disorder is best evidenced by which behavior? a) Serves as a counselor at a camp for hemophiliacs b) Keeps plastic bags of ice in the freezer c) Wears extra pads when playing football d) Chew food slowly to prevent injury to the gums 312. The nurse is supervising a home health aide performing care for a cient with end stage amyotrophic lateral sclerosis (ALS). It is most important for the nurse to observe which task? a) Performing range of motion exercises b) Caring for an indwelling urinary catheter c) Feeding the client a meal d) Transferring to the bedside commode 313. The healthcare provider prescribes a placebo to be administered instead of pain medication. What intervention should the nurse implement? a) Discuss ethical concerns about placebo use with the healthcare provider b) Administer the placebo as prescribed when the client complains of pain c) Tell the charge nurse about the prescribed placebo and refuse to administer it c) Inform the client that the provider prescribed a placebo instead of pain medication 314. The mother of an 11-year-old boy who has juvenile arthiritis tells the nurse, “I really don’t want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting.” Which information is most important for the nurse to provide this mother? a) Encourage quiet activities such as watching television as a pain distracter b) Giving pain medication around the clock helps control the pain c) The use of hot baths can be used as an alternative for pain d) The child should be encouraged to rest when he experiences pain 315. A client with heart failure, who is taking furosemide (Lasix), complains of muscle cramps a weakness in the lower extremities. Which action should the nurse implement? Collect blood for serum electrolytes. 316. A registered nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP) are working as a team to provide care for an acutely ill client requiring immediate bedside insertion of a chest tube. Which assignment is the best use of each person’s skills? A. The UAP obtains an oxygen saturation level while the Rn reports findings to the healthcare provider. B. The PN instructs the family about the need for chest tube insertion while the RN obtains vital signs. C. The UAP listens to breath sounds while the RN witnesses the informed consent. D. The RN inserts the chest tube immediately after the PN cleanses the skin at the insertion site. 317. An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drugs is most important for the nurse to obtain? His level of activity. 318. Two days after his last drink, a male client with a history of heavy and prolonged alcoholism becomes agitated, and yells at his wife and children; “Stay away from me” His vital signs are elevated. What nursing problem has the highest priority? Risk for injury. 319. While inserting an indwelling urinary catheter in a female client, the nurse observes urine flow in the tubing? What action should be taken next? Inflate the balloon with 5 ml of sterile water. 321. One week after an above-the-knee amputation (AKA) of the left leg, “numb” . Reinforce learning about the cause of this sensation. 322. Which laboratory test result is most important for the nurse to report to the surgeon prior to client’s scheduled abdominal surgery? Serum creatinine of 5 mg/dl. 323. A client with hyperthyroidism has a serum calcium level of 13.5 mg/dl(3.375 mmol/LSI). report a change in the client’s level of counsciousness. 324. A male client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. He reports feeling increasingly fatigued. Which laboratory value should the nurse review? A. Platelet count. B. Complete blood count C. Serum electrolytes. D. Liver enzymes. 325. A young adult male who was recently diagnosed with bipolar disorders takes lithium carbonate daily. …. His serum lithium levels should be routinely evaluated. 326. The nurse learns in report that a client is stupors. What assessment should the nurse perform to confirm this report? Determine the response to stimuli. 327. The parent of a 4-week old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain? Degree of forcefulness of vomiting episodes. 329 A mother brings her 2 month old infant to the clinic for a well-baby appointment. The nurse obtains a history and conducts a physical assessment. Which finding requires the most immediate intervention? a. Bilateral retinal hemorrhages. b. A positive Orlolani maneuver. c. History of poor feeding and vomiting. d. Mother describes infant as irritable. 330. A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care? a- Confusion. b- Peripheral neuropathy. c- Right lower abdominal pain. d- Depression. 331. An infant is unresponsive and breathe. Prior to starting CPR, which site should the nurse palpate for a pulse? A A:C Show Less