ATI Comprehensive Exam 2013 FORM B

ATI COMP 2013 FORM B 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statement ...

ATI COMP 2013 FORM B 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how ofen do you drink alcohol d) Tell me about your school schedule 2) *A nurse is observing bonding to the client her newborn. Which of following actons by the client requires the nurse to intervene? a) Holding the newborn in an en face positon b) Asking the father to change the newborn's diaper c) Requestng the nurse take the newborn nursery so she can rest d) Viewing the newborn’s actons to be uncooperatve 3) A nurse is caring for client who is taking levothyroxin. Which of the following fndings should indicate that the medicaton is effectve? a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism) b) Decreased blood pressure c) Absence of seizures d) Decrease inflammaton 4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructons would you include in the teaching? a) Contact provider if the cord stll turns black (it’s going to turn black) b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser) c) Keep the cord dry untl it falls off (cord should be kept clean and dry to prevent infecton) d) The cord stump will fall off in fve days (cord falls off in 10-14 days) 5) A nurse is assessing a client in the PACU. Which of the following fndings indicates decreased cardiac output? a) Shivering b) Oliguria c) Bradypnea d) Constricted pupils 6) A nurse is assistng with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identfy as the priority? a) A client that has massive head trauma b) A client has full thickness burns to face and trunk c) A client with indicatons of hypovolemic shock d) A client with open fracture of the lower extremity 7) A nurse is a receiving report on four clients. Which of the following clients should the nurse assess frst? a) A client who has illeal conduit and mucus in the pouch b) Client pleasant arteriovenous additonal vibraton palpated c) A client whose chronic kidney disease with cloudy diasylate outlow d) A client was transurethral resecton of the prostate with a red tnged urine in the bag 8) A nurse is caring for a client just received the frst dose of lisinopril. The following is an appropriate nursing interventon? a) Place’s cardiac monitoring b) Monitor the clients oxygen saturaton level c) Provide standby assist with the client from bed d) Encourage foods high in potassium 9) A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early deceleratons. Which the following should the nurse expect? a) Feta hypoxia b) Abrupto placentae c) Post maturity d) Head Compression 10) A nurse is caring for a client who has chronic kidney disease. The nurse should identfy which of the following laboratory values as in an indicaton for hemodialysis? 1 of 47a) glomerular fltraton rate of 14 mL/ minute b) BUN 16 mg/DL c) serum magnesium 1.8 mg mg/dl d) Serum phosphorus 4.0 mg/dL 11) A nurse is caring for an infant who has a prescripton for contnuous pulse oximetry. The following is an appropriate acton for the nurse to take? a) Placed infant under radiant warmer b) Move the probe site every 3 hours c) Heat the skin one minute prior to placing the program d) Placed a sensor on the index fnger 12) A nurse in a mental health facility receives a change of shif report on for clients. Which of the following clients should the nurse plan to assess frst? a) Client placed in restraints to the aggressive behavior b) A new limited client pleasures history of 4.5 kg weight loss in the past two months c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety d) Applied he’ll be receiving his frst ECT treatment today 13) A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate descripton of the use of hypnosis during labor? a) Hypnosis focuses on the biofeedback as a relaxaton technique b) Hypnosis promotes increased control of her pain percepton during contractons c) Hypnosis uses therapeutc touch to reduce anxiety during labor d) Hypnosis provides instructon to minimize pain 14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for thef is addressing the group. Which of the following is an example of reacton formaton? (rxn formaton is when you use opposite feelings; ex: being super nice to someone you dislike) a) I steal things because it’s the only way I can keep my mind off my bad marriage b) I can’t believe I was accused of something I didn’t do c) I don’t want talk about my feelings right now. We will talk more next tme d) I think that people just you’re just lazy and should earn money honestly 15) A nurse is obtaining the medical history of a client who has a new prescripton for isosorbide monottrate. Which of the following should the nurse identfy as a contraindicaton to medicaton? a) Glaucoma b) Hypertension c) Polycythemia d) Migraine headaches 16) ? 17) The nurses is caring for a client recovering from an acute myocardial infarcton. Which following interventon should the nurse include in the point of care? a) Draw a troponin level every four hours b) Performance EKG every 12 hours c) Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitaton consult 18) A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider? a) WBC 3,000/mm3 b) Hemoglobin 14 g/dl c) Platelet 250,000/mm3 d) aPTT 30 seconds 19) Home health nurse is carefully planned for Alzheimer’s disease. To the following acton should the nurse include in the plan of care a) Place a daily calendar in the kitchen b) Replace buton clothing with zippered items c) Replace the carpet with hardwood floors d) Create variaton in daily routne 2 of 4720) Nurse is performing change of shif assessments on 4 clients. Which of the following fndings should the nurse report to provider frst? a) The client was cystc fbrosis and has a thick productve clock and reports thirst b) Client who has gastroenterits and is lethargic and confused c) The Client has diabetes mellitus has morning fastng Legal cost of 185 mg over deal d) The client was sick of signing it reports pain 15 minutes afer receiving oral analgesic 21) A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constpaton. Which of the following statements by the nurse is appropriate? a) Decrease taking vitamins and supplements to every other day b) Eat 15 g of fber per day c) Consume 48 ounces of water each day (need at least 64 oz) d) Drink hot water with lemon juice each morning when you wake up 22) ? 23) A nurse is caring for a client who is preparing his advance directves. Which is the following statements by the client indicates an understanding of advanced directves? select all that apply a) I can’t change my instructons once a minute b) My doctor will need to approve my advance directves c) I need an atorney to witness my signature on the advance directves d) I have the right to refuse treatment e) My health care proxy can make medical decisions for me 24) A nurse is caring for a client who is at 32 weeks gestaton and has a history of cardiac disease. Which of the following positons should the nurse place the client to best promote optmal cardiac output? a) The chest b) Standing c) Supine d) Lef lateral 25) A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP? a) Client who has chronic obstructve pulmonary disease and needs guidance on incentve spirometry b) Client who has awoken following a bronchoscopy and requests a drink c) Client who had a myocardial infarcton 3 days ago reports chest discomfort d) Client who had a cerebrovascular accident two days ago and needs help toiletng 26) Nurse providing discharge teaching to the client who has schizophrenia and is startng therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? a) Constpaton b) blurred vision c) Fever d) Dry Mouth 27) A nurse observes an AP providing care to a child who is in skeletal tracton. Which of the following acton requires interventon? a) Providing a high protein snack b) Assistng the child to repositon c) Placing weights as a child’s bed d) Massaging pressure points-causes skin breakdown 28) A nurse is planning to delegate to an AP the fastng blood glucose testng for a client who has diabetes mellitus. Which of the following acton should the nurse take? a) Determine if the AP is qualifed to perform the test. b) Help the AP performed the blood glucose test c) Assign the AP to ask the client is taking his diabetc medicaton today d) Have AP check the medical record for prior blood glucose test results 29) A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement ofcer. The client has disorganized, incoherent speech with loose associatons and religious content. You should recognize the signs and symptoms as being consistent with which of the following? a) Alzheimer’s disease b) Schizophrenia c) Substance intoxicaton d) Depression 3 of 4730) A nurse is caring for a child who has infectous mononucleosis.. Which of the following fndings are associated with this diagnosis? Select all that apply a) splenomegaly b) Koplik spots (this is associated with measles) c) Malaise d) Vertgo e) Sore throat 31) Nurse is performing dressing change for client was a sacral wound using negatve pressure wound therapy. Which The following actons should the nurse take frst? a) Apply skin preparaton to wound edges. b) Normal saline c) Don sterile gloves d) Determine pain level 32) A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermitent sucton. Which the following assessment fndings should indicate to the nurse that the NG tube may not be functoning properly? a) Drainage fluid is greenish-yellow b) aspirate pH of 3 c) Abdominal rigidity d) air bubbles noted in the NG tube 33) A nurse is preparing to administer TPN with added fat supplements to a client who has malnutriton. Which of the following acton should the nurse take? a) Piggyback 0.9 sodium chloride with TPN soluton b) Check for an allergy to eggs c) Discuss the TPS soluton for 12 hours d) Monitor for hypoglycemia 34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identfy as a beneft? (A/C?) a) Systemic analgesic effect b) increase in your metabolism c) Decreased capillary permeability d) Vasodilaton 35) Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to a) Perform weight bearing exercises b) Avoid crossing the legs beyond the midline c) Avoid sitng in one positon for prolonged periods d) Split affected area 36) A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positve Trousseau’s sign b) A client who was Clostridium difcile with acute diarrhea c) A client who is acute kidney injury and urine with a low specifc gravity d) The client who has oral cancer and reports a sore on his gums 37) Nurses caring for a client was congestve heart failure. Which of the following prescriptons for the provider should the nurse antcipate? a) Call the provider to clients respiratory rate is less 18/min b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr c) Give the client enalapril 2.5 mg PO twice daily d) Call the provider if the clients pulse rate is less than 80/min 38) A nurse is caring for a client who has a prescripton for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medicaton treatment plan? a) I will be able startng this medicaton with feel beter b) I can expect to urinate frequently while on this medicaton c) I understand I may experience difculty sleeping on this medicaton 4 of 47d) I should decrease my sodium intake while on this medicaton 39) A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing interventon?” a) Offer to speak to the client’s husband regarding his abuse behavior. b) Help the client to recognize the signs of escalaton of abuse behavior c) Assist the client to identfy personal behaviors that trigger abusive behavior d) Assist the client to Reports abusive behavior to the proper authority 40) A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? a) Why do you think your life is not worth it anymore? b) Do you have a plan to end your life? c) I need to know what you mean my misery d) You can trust me and tell me what you’re thinking 41) A nurse is caring for a client who has schizophrenia. Which of the following assessment fndings should the nurse expect? a) Decreased level consciousness b) Unable to identfy common objects c) Poor problem solving ability d) Preoccupaton was somatc disturbances 42) A nurse is caring for a client who has deep vein thrombosis of the lef lower extremity. Which of the following acton should nurse take? There are 3 tabs that contain separate categories of data. a) Positon the client with the affected extremity lower than the heart b) Administraton of acetaminophen c) Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion 43) Is caring for clients was a new prescripton for enoxaparin for the preventon of DVT. Which of the following is an appropriate acton by the nurse? a) Expel air bubble at the top of the preflled syringe b) Massage the injecton site to evenly distribute the medicaton c) Inject the medicaton the lateral abdominal wall d) Administer an NSAID for injecton site discomfort 44) Nurses caring for four clients. Which of the following client data should the nurse report to the provider? a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing b) Client was a total of 110 mL of serosanguineous fluid from the Jackson Prat drain within the frst 24 hour following surgery c) Client who is 4 hrs postoperatve and has a heart rate of 98 per minute d) The client was a prescripton for chemotherapy and an absolute neutrophil count of 75/mm3 45) Nurses caring for client was in end-stage osteoporosis and is reportng severe pain. Clients respiratory rate is 14 per minute. Which of the following medicatons should the nurse expect to be the highest priority to administer to the client? a) Promethazine b) Hydromorphone c) Ketorolac d) Amitriptyline 46) A nurse is caring for a client who has DVT. Which of the following instructons the nurse include in the plan of care? a) Live with the clients fluid intake to 1500 mL per day b) Massage place affected extremity to relieve pain c) Apply cold packs of clients affected extremity d) Elevate the client’s affected extremity when in bed 47) A nurse is caring for a client who is receiving oxytocin IV for augmentaton of labor. The client’s contractons are occurring every 45 seconds with a nine seconds duraton in the fetal heart rate is 170 to 180/minute. Which of the following actons should nurse take? a) Discontnue oxytocin infusion b) Increased oxytocin infusion c) Decreased oxytocin infusion 5 of 47d) Maintain oxytocin infusion 48) A nurse is admitng a client who is in labor and at 38 wks of gestaton to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questons is most appropriate for the nurse to ask the client? a) Have your membranes ruptured? b) How far apart are your contractons? c) Do you have any actve lesions? d) Are you positve for beta strap? 49) Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructons should the nurse include? a) Take with meals b) Take at bedtme c) Take with a glass of milk d) Take with a glass of orange juice 50) Four clients present to the emergency department. The nurse should plan to see which of the following clients frst? a) A 6 year old client whose lef shoulder is dislocated b) A 26 year old client for sickle cell disease and a severe joint pain c) A 76 year old client was confused, febrile and has foul smelling urine - ut d) A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke 51) A nurse is completng a dietary assessment for client who is Jewish and observes kosher dietary practces. Which of the following behaviors should the nurse expect to fnd? a) Leavened bread maybe eaten during Passover. b) Shellfsh is commonly consumed in the diet. c) Meat and dairy products are eaten separately. d) Fastng from meat occurs during Hanukkah. 52) ? 53) A nurse is in an ER caring for client of multple wounds due to a motor vehicle crash. Which of the following interventons are appropriate? Select all that apply a) Apply direct pressure to bleeding wounds b) Clean rest last ratons and abrasions with hydrogen peroxide c) Cover wounds with a sterile dressing d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccinaton. 54) The nurses reviewing clients admission laboratory results. Which of the fndings required further evaluaton? a) Sodium 138 b) Creatnine 1.8 c) Hemoglobin 15 d) Potassium 4.2 55) A nurse is providing teaching for a client has a new prescripton for methadone. Which of the phone following client statements indicates need for further teaching? a) I understand the methadone tends to slow my breathing b) I understand the methadone may cause me to have difculty sleeping c) I will avoid alcohol while I’m taking this medicaton d) I’ll change positons gradually especially from lying down to standing 56) Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluaton? a) Premature infant with a poor suck reflex and failure to thrive b) An older adults who has difculty taking in fluids c) Adolescent who anorexia who is cachectc d) A middle aged adults was gastroesophageal reflux disease 57) A nurse is caring for a group of clients. Which of the following client should nurse assess frst? a) A client whose benign prostatc hyperplasia and is unable to urinate b) The client was heart failure and report shortness of breath while ambulatng c) A client who is open cholecystectomy and has green drainage from the T-tube d) A client whose abdominal pain and is vomitng coffee ground emesis 6 of 4758) A nurse is taking a medicaton history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medicatons to the nurses instruct the client to discontnue 48 hrs prior to the procedure? a) Atorvastatn b) Digoxin c) Nifedipine d) Metormin 59) The nurses assessing client with postraumatc stress disorder. Which of the following fndings to the nurse expect to fnd? a) Dependence on family and friends b) Loss of interest in usual actvites c) Ritualistc behavior d) Passive aggressive behavior 60) A nurse working in a long-term care facility is caring for an older adult client has dementa. The clients ofen agitated and frequently wanders the halls. Which of the following interventon should the nurse include in the plan of care? a) Give the client several choices when scheduling actvites. b) Confront the client regarding unacceptable behavior c) Maintain Nutritonal requirements by offering fnger foods d) Stmulate the client by leaving the television on throughout the day 61) A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse atend to frst? a) A client who has begun to demonstrate catatonic behavior b) The client was compulsive behavior and is frequently drinking from the water fountain c) Client was having auditory hallucinatons is becoming agitated d) A client was making sexual comments to clients of the opposite sex 62) A nurse is caring for the full term newborn immediately following birth. Which of the following actons should the nurse take frst? a) Instll erythromycin ophthalmic ointment and the newborn’s eyes. b) Place identfcaton bracelets on the newborn. c) Weigh the newborn. d) Dry the newborn 63) A nurse receives report on a group of clients. Which of the following client should the nurse atend to frst? a) A client who was admited with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula b) A client was admited with angina and reports lef arm pain of 4 on a scale of 0 to 10 c) The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid 64) A client at 38 weeks of gestaton enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor? a) The client reports the urge to push b) The cervix is dilated 2 cm c) Contractons are 2 to 3 minutes apart d) The client reports nausea and vomitng 65) The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned? a) An AP is to calculate intake and output every two hours for client in acute renal failure. b) An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy c) A licensed practcal nurse is to check nasogastric tube placement for client list had a bowel resecton. d) A licensed practcal nurses to provide inital feeding for client who had a cerebrovascular accident. 66) A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following fndings requires immediate interventon? a) pruiritus under the cast b) Localized stabbing pain upon movement c) paresthesia of the distal extremity d) Edema present when leg is in the dependent positon 7 of 4767) The nurses providing care for preschoolers with acute gastroenterits. Basing informaton below which of the following is an appropriate nursing acton? Click on the links of this below for additonal client informaton a) Offer the child a cup of chicken broth. b) Encourage the child’s intake of gelatn. c) Administer oral rehydraton solutons. d) Insttute a banana, Rice, applesauce, and toast diet. 68) The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory fndings to determine the effectveness of the medicaton? a) Serum chloride b) Uric acid level c) Serum albumin d) Magnesium level 69) A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion? a) Ventricular asystole b) Third-degree AV block c) Atrial fbrillaton d) Ventricular fbrillaton 70) Nurse managers preparing an educatonal program on infecton control measures. Which of the following should the nurse include when discussing contact precautons? a) Scarlet fever b) Herpes simplex c) Varicella d) Streptococcal pharyngits 71) A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following fndings should the nurse report to the provider immediately? a) The clinic experiences coughing and wheezing afer eatng. b) The client reports abdominal pain at a fve on a scale of 0 to 10. c) The client experience is a drop in oxygen saturaton to 91% while eatng. d) The client reports a burning sensaton in epigastric area. 72) A nurse and an assistve personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP? a) Applying condom catheter for client for spinal cord injury b) Administratve oral fluids to client was dysphasia c) Documentng the report of pain from client who is postoperatve d) Reviewing actve range of moton exercises with a client who is had a stroke 73) A nurse from the state health department this is instructng a group nurses regarding reportable infectons. Which of the following infectons should the nurse report to the CDC? a) Candida albicans b) Herpes simplex virus 2 c) staphylococcus aureus d) Lyme disease 74) The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority fnding by the nurse? a) A pain score 7 on a scale of 0 to 10 b) Shortness of breath c) New onset of a new enuresis d) Priapism 75) Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following fndings requires further assessment by nurse? a) Glascow scale score a 15 b) Blood drainage on inital dressing measuring 3 cm c) Report of dry mouth d) Urinary output greater than fluid intake 8 of 4776) A client with the lef leg cast is using crutches for ambulaton. The nurse recognizes client needs further instructon of the client a) Flexes elbows at 30 degrees when using the handgrips b) Maintains 3 to 4 fnger width between the crutch pad and axilla c) Places the crutches 6 inches in front and side of each foot when standing. d) Pushes up from a chair with crutches on the unaffected side. 77) A nurse is caring for a toddler who has respiratory syncytal virus. Which of the following actons should the nurse plan to take? a) Use a designated stethoscope when caring for the toddler. b) Wear an N95 respiratory mask while caring for the toddler. c) Remove the disposable gown afer leaving the toddler’s room d) Place the toddler in a room with negatve air pressure. 78) A nurse is admitng to a client to emergency department and initates contnuous cardiac monitoring. Which of the following ECG with strips indicates sinus tachycardia? b) 79) A nurse is planning care for client to prevent complicatons of immobility. With the following actons should the nurse including the plan of care? a) Massage lower extremites daily to prevent DVT b) Limit intake of Food high in calcium to prevent renal calculi. c) Encourage client to lie supine prevent constpaton. d) Remove ant embolism stockings for 3 hours each day to decreased skin breakdown. 80) A nurse discovers that the wrong dosage of medicaton was given to client. When determining what acton to take your should recognize that which of the following ethical principles should be applied? a) Utlity b) Paternalism c) Veracity d) Fidelity 81) ? 82) A nurse is review in the prescripton for doxazosin with a client. Which of the following should be included in the teaching? a) Decrease caloric intake to reduce weight gain. b) Increased dietary fber to prevent constpaton. c) Rise slowly when sitng up from bed. d) Take this medicaton each morning. 83) Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching? a) Exercising an hour before bedtme b) Take a short nap today c) Keep bedroom cool at night d) Consume a high carbohydrate snack at bedtme. 84) A nurse is caring for client who has a stool culture that is positve for Clostridium difcile. Which of the following infecton control precautons is appropriate? a) Wear a face shield prior into entering the room. b) Place the client private room. 9 of 47c) Place the client in a negatve pressure room. d) Use alcohol based hand rub following client care. 85) A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following interventon should the nurse including the plan of care? a) Perform actve range of moton exercises. b) Perform neurological checks every 4 hours. c) Sucton the airway frequently. d) Maintain the head at a midline positon. 86) The nurse is assessing a client is receiving radiaton therapy. Which of the following fndings should the nurse expect? a) White blood cell count at 12,500 mm3 b) Excessive salivaton c) +3 pitng edema d) Platelets 95,000 mm3 87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identfy that which of the following medicatons is contraindicated? a) Methylergonovine. b) Misoprostol c) Dinoprostone d) Oxytocin 88) A nurse is caring for client was GERD. Which of the following assessment fndings the nurse expect to fnd? a) Shortness of breath b) Rebound tenderness c) Atypical chest pain d) Vomitng blood 89) A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing acton? a) Ensure eye shield is covering the eyes. b) Apply loton to expose skin. c) Offer glucose water between feedings. d) Discontnue breast-feeding during treatment. 90) This is assessing clients as had a long arm cast. Which of the following fndings of the dress moderate and when assessing for acute compartment syndrome? a) Shortness of breath b) Petechiae c) Change in mental status d) Edema 91) I Just came from client is receiving IV moderate (Conscious) sedaton with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate acton by the nurse? a) Placed the client in a prone propositon. b) Implement Positve pressure ventlaton. c) Perform nasopharyngeal suctoning. d) administer flumazenil 92) A nurses in a hospital cafeteria overhears two assistve personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actons should the nurse take frst? a) Report the AP’s behavior to the supervisor. b) Completed instant report regarding the Aps conversaton. c) Provide the AP with writen documentaton regarding client confdentality d) Tell the AP to discontnue their conversaton 93) A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following? a) testcular Cancer b) Obesity c) Stroke d) Melanoma 10 of 4794) A nurse is caring for a client who sprained his lef ankle 12 hrs ago . Which of the following prescripton is given by the provider should the nurse clarify? a) Over the fact that extremites and two pillows. b) Apply heat to affect extremity for 45 minutes on the 45 is off. c) wrap the affected extremity with a compression dressing. d) Assess the affected extremity for sensaton movement impulse every four hours 95) A nurse is providing dietary teachings for client who has hepatc encephalopathy. Which the following food selectons indicates that client understands teaching? a) A sandwich and milkshake b) Rice with black beans c) Cotage cheese and tuna letuce d) Three egg omelete with low-sodium ham 96) A nurse is planning care for client sealed radiaton implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a) Remove dirty linens from the room afer double bagging. b) Wear a dosimeter flm badge while in the client’s room c) Limit each of the clients is yours to one hour per day. d) Ensure family members remain at least 3 feet from the client. 97) A nurses for Caring for four clients. Which of the following client should the nurse care for frst? a) A client to receive a chemotherapy treatment or frst natonal b) A client who has an appendectomy to these don’t has diminished all sounds c) A client is hypothyroidism and his stuporous d) A client who is a burn requiring a sterile dressing change 98) The nurses planning care for newly admited adolescent who has bacterial meningits. Which the following instructons is appropriate for the nurse to include in the plan of care? a) Initate droplet precautons for the client b) Assisted client to supine positon c) Performing Glasgow coma scale every 24 hrs d) Recommend prophylactc acyclovir there for the clients family. 99) Nurse is giving discharge instructons to client has new ileostomy. The nurse should recognize that the teaching has been effectve when the client states. a) I want sure that my medicatons are enteric coated b) My stoma will drain liquid fluid contnuously c) I will change my pump system every two weeks d) My stoma size will stay the same even afer healed 100) A nurse in a provider’s ofce is interviewing a client who is requestng an oral contraceptve. Which of the following fndings in the client’s history is a contraindicaton to use in combinaton oral contraceptves? a) thyroid disease b) Allergy to penicillin c) impaired liver functon d) abnormal blood glucose 101) The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching? a) This medicaton can be used to help you when have an acute asthma atack b) This medicaton should be taken before exercise and physical actvity c) This medicaton can be taken for 10 days and then gradually discontnued d) This medicaton helps decrease swelling and mucus producton 102) I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess frst? a) A client who is receiving warfarin and has and INR of 3.3 b) A client who has an acute kidney injury, a creatnine of 4 mg/dL, and a BUN 52 mg/dL c) A client who had a NG tube inserted 6 hr ago and has abdominal distenton d) A client who is 4 hr postoperatve following a thyroidectomy and reports fullness in the back of the throat 11 of 47103) A nurse is assessing a client who has pericardits. Which of the following fndings is priority a) Paradoxical pulse pg. 389 under complicatons b) dependent edema c) Pericardial fricton rub d) Substernal chest pain 104) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching? a) Hydrogen peroxide b) Chlorhexidine c) Isopropyl alcohol d) Chlorine bleach 105) *A nurse is preparing to feed a newly admited patent with dysphagia. Which of the following actons in response take? a) instruct the client to lif her chin when swallowing b) discourage the client from coughing during feedings c) Sit at or below the clients eye level during feedings. d) Talk with the client during her feeding. 106) A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistve personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement consttutes which of the following torts? a) Assault b) Batery c) Malpractce d) Negligence 107) A charge nurse is evaluatng the tme management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following? a) Re-Evaluate priorites halfway through the shif b) Delegate changing sterile dressing for licensed practcal nurse c) Groups actvites for the Same client d) Works on several tasks simultaneously 108) A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority fnding? a) Feeling flushed and warm b) Abdominal fullness c) Swollen lips d) Metallic taste in mouth 109) A nurse is planning to delegate client assignments to the assistve personnel. which of the following task is appropriate for the nurse to delegate? a) Just the flow rate of the clients oxygen tank b) Collectng urine sample c) Measuring the clients pain level d) Monitoring blood glucose levels 110) A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure? a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92 111) A nurse if caring for a group of clients in a medical surgical unit. Which of the following situatons requires completon of an incident report? a) A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump has malfunctoned c) A client who requires inserton of NG tube due to a bowel obstructon d) A client who is absent bell sounds following a gastrectomy 112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor? a) Fastng blood glucose b) Carbohydrate intake 12 of 47c) Hematocrit d) Weight 113) The nurses providing discharge instructons about engorgement for client has decided not to breasteed. Which of the following statements by the client indicates a need for further instructon by the nurse? a) I can wear support bra b) I will play cold compression my breasts c) I will manually express breastmilk d) I can take a mild analgesic 114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by contnuous IV infusion. Which of the following client fndings indicates medicaton toxicity? a) Blood glucose of 150 mg/dL b) Urine output of 20 mL per hour c) Systolic blood pressure at 140 mm Hg d) BUN 20 mg/dL 115) The nurse is completng an assessment for newborn who is 2 hrs old. Which of the following fndings are indicatve of cold stress? a) Respiratory rate of 60 per minute b) Jiteriness of the hands c) Diaphoretc d) Bounding peripheral pulses in all extremites 116. A nurse is planning care for four clients. Which of the following clients is the highest priority? a. A client who is dry, black eschar on the heel b. A client who is wearing an arm cast and reports numb fngers c. The client was reddened skin area with blanching around the coccyx d. The client who has frequent incontnence 117. A nurse is caring for a male adolescent client who has heart failure. Based on the client’s chart fnds. Which of the following actons should the nurse plan to take? a. Withholds spiranolactone b. Administer ferrous sulfate c. Administer furosemide d. Withhold digoxin (0.8-2.0) 118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestatons are associated with this fnding? a. Confusion (hypoglycemia) b. Thirst c. Diaphoresis (hypoglycemia) d. Shakiness (hypoglycemia) 119. A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventlator. Which of the following allergies is a contraindicaton to the medicaton? a. Eggs b. Milk c. Shrimp d. Peanuts 120. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this fnding which of the following in the client’s chart? a. Echolalia b. Associatve looseness c. Neologisms d. Concrete thinking 121. A nurse caring for a client who is receiving total parental nutriton. Which of the following assessment fndings required immediate interventon by the nurse? 13 of 47a. prealbumin level of 20 mg/dL b. Weight increase of two kg/day c. Temperature of 37.6°C d. Blood glucose level of 120 mg/dL 122. A nurse in the telemetry unit is receiving the laboratory fndings for adult male client who’s been treated for myocardial functon. The following is an expected fnding for the client? a. Troponin 1 (TNI) 8 ng/ml b. Brain natriuretc peptde (BNP) 10 ng/L c. Alanine aminotransferase (ALT 45 unit/L d. High density lipoprotein (HDL) 75 mg/dl 123. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment? a. paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg c. HCO2 level of 25 mEq/L d. pH level of 7.37 124. A nurse is teaching a client about nutritonal intake. The nurse should include which of the following in the teaching? a. "Carbohydrates should be at least 45% of your caloric intake." b. "Protein should be at least 55% of your calorie intake." c. "Carbohydrates should be at least 30% of your caloric intake." d. "Protein should be at least 60% of your caloric intake." 125. A nurse is caring for a client who has a prescripton for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following tmes? a. 2100 b. 0900 c. 1300 d. 1800 126. A nurse is planning an educaton session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? a. diaphoresis b. polyuria c. abdominal pain d. thirst 127. A nurse in an urgent-care clinic is collectng admission history from a client who is 16 weeks of gestaton and has bacterial vaginosis. The nurse should recognize that which of the following clinical fndings are associated with this infecton? a. Frequency and dysuria b. Profuse milky white discharge c. Hematuria d. Low grade fever 128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initatng feeding? a. beef broth b. oatmeal c. apple juice d. toast 129. A nurse receives a change-of-shif report. Which of the following clients should the nurse atend to frst? a. A client who reports tngling in the fngers following a thyroidectorny b. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr c. A client who is in a long leg cast and reports cool feet bilaterally d. A client who has a productve cough and an oral temperature of 36° C (96.80 F) 14 of 47130. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumpton of which of the following foods? a. spinach b. peanut buter c. ground beef d. carrots 131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negatve. The newborns blood type is B positve. Which of the following statements is appropriate? a. You only need to receive Rh immune globulin if you have a positve blood type." b. You should receive Rh immune globulin within 72 hours of delivery." c. "Both you and your baby should receive Rh immune globulin at your -week appointment." d. "immune globulin is not necessary since this is your second pregnancy." 132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash afer a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate? a. You had no way of knowing this would happen." b. Most parents blame themselves when losing a child." c. Tell me why you feel this is your fault." d. You appear to be feeling overwhelmed" 133. A nurse is educatng a client about caloric intake and weight reducton. Which of the following client statements indicates an understanding of the teaching? a. “If I eat 500 fewer calories per day, I should lose 1 pound per week.” b. “ If I eat 500 fewer calories per day, I should lose 1 pound per week." c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week." d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week." e. "If I eat 300 fewer calories per day, I should lose 1 pound per week.” 134. A nurses is teaching post-operatve care with the parents of a toddler following a clef palate repair. Which of the following should be included in the teaching? a. Provide an orthodontc pacifer for comfort. b. Offer fluids by using a straw. c. Cleanse suture line with a coton tp swab. d. Remove elbow splints periodically to perform range of moton. 135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistve personnel? a. Perform chest compressions during cardiac resuscitaton. b. Perform a dressing change for a new amputee. c. Assess effectveness of antemetc medicaton. d. Provide discharge instructons 136. A nurse in an emergency department is serving on a commitee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestaton of smallpox? a. Bloody diarrhea b. Ptosis of the eyelids c. Descending paralysis d. Rash in the mouth 137. A nurse is preparing to perform closed intermitent bladder irrigaton for a client following a transurethral resecton of the prostate (TURP). Which of the following actons is appropriate by the nurse? a. Aspirate the irrigaton soluton from the bladder. b. Insert the tp of the irrigaton syringe into the catheter opening. c. Apply sterile gloves. 1296 in med surgical book d. open the flow clamp to the irrigatng fluid infusion tubing. 138. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment fndings should the nurse recognize as a long-term side effect of this medicaton? a. Lipsmacking 15 of 47b. Agranulocytosis c. Clang associaton d. Alopecia 139. A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care? a. Place the client in seclusion when she is confused. b. Request a prescripton for PRN restraints when the client is wandering. c. Dim the lightng in the clients room. d. Leave one side rail up on the clients bed. 140. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management? a. Postorandial blood glucose b. Glycosylated hemoglobin - Ha1c c. Glucose tolerance test d. Fastng blood glucose 141. A nurse on a pediatric care unit is delegatng client care. Which of the following tasks should the nurse delegate to an assistve personnel? a. Initate a dietary consult for a toddler. b. Administer a glycerin suppository to a preschool-age child. c. Evaluate gastric residual following intermitent feeding of an adolescent. d. Transport a school-age child to x-ray. 142. A nurse is caring for a client who has been taking propranolol. Which of the following fndings indicates a need to withhold the medicaton? a. sodium 130 mEq/L b. Blood pressure 156/90 mm Hg c. Potassium 5.2 mEq/L d. Pulse 54/min 143. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse? a. Apologize to the others for your behavior." b. I am disappointed that you contnue to act out when you are angry." c. Come outside with me for a walk." d. If you dont calm down, you will have to go into seclusion." 144. A nurse is caring for a client who has human immunodefciency virus (HIV) with neutropenia. Which of the following precautons should the nurse take while caring for this client a. Wear an N95 respirator while caring for the client. b. Use a dedicated stethoscope for the client. c. Insert an indwelling urinary catheter to monitor urinary output. d. Monitor the client’s vital signs every 8 hr. 145. A nurse is checking laboratory results for a client. Which of the following laboratory fndings indicates hypervolemia? a. serum sodium 138 mEq/L b. Urine specifc gravity 1.001 c. serum calcium 10 mg/dL d. Urine pH 6 146. A nurse is caring for a group of clients in a long-term care facility. Which of the following situatons should the nurse recognize as a safety hazard? a. A client’s wrist restraints ted to the bed rails b. A clients bedside table placed across the foot of the bed c. A meal tray lef at the bedside from breakfast d. A call light extension cord pinned to the bedspread 147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? 16 of 47a. I’d like to know more about what’s bothering you." b. "Why are you feeling this way" c. "You did the right thing by bringing him here." d. "I’m sure your father doesn’t blame you." 148. A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructons when preparing the client for discharge? a. start each meal with a protein source. b. Consume at least 25 g of fber daily. c. Check your blood glucose level before each meal. d. Limit your meals to three tmes per day. 149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following fndings requires interventon by the nurse? a. Tidaling with spontaneous respiratons b. Drainage collecton chamber is 1/3 full c. 1 cm of water present in the water seal chamber d. Sucton chamber pressure of -20 cm H20 150. A provider has writen a do not resuscitate order for a client who is comatose and does not have advance directves. A member of the clients family says to the nurse, “I wonder when the doctor will tell us what’s going on" Which of the following actons should the nurse take frst a. Request that the provider provide more informaton to the family. b. Refer the family to a support group for grief counseling. c. Offer to answer questons that family members have. d. Ask the family what the provider has discussed with them. 151. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is a. scaly and red b. asymmetric, with variegated coloring c. frm and rubbery d. brown with a wart-like texture 152. A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process? a. Decreased sense of taste b. Decreased blood pressure c. Increased gastric secretons d. Increased accommodaton to near vision 153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care? a. Administer disulfram. b. Provide frequent orientaton to tme and place. c. Engage the client in group therapy. d. Perform gastric lavage. 154. A nurse is assessing a client’s cardiovascular system. Identfy where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortc heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork untl the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) 17 of 47a. Top lef site 155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult? a. Nursing manager colleagues b. Evidence-based practce data c. Hospital administrators d. Protocols in other hospitals 156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following fndings should the nurse expect? (Select all that apply) a. Facial flushing b. Syncope c. Diaphoresis d. Vertgo e. Bradycardia 157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following fndings should the nurse expect? a. feelings of dread b. rapid speech c. purposeless actvity d. heightened perceptual feld 158. A nurse is delegatng tasks to an assistve personnel. Which of the following instructons demonstrates appropriate communicaton of the task? a. "Take a blood glucose fngerstck on the client in room 102 before breakfast and then place the glucometer into the docking staton." b. "Obtain a blood pressure reading from the client in room 116 afer lunch and report a systolic level less than 90." c. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of breath." d. "Turn the client in room 126 to prevent pressure areas on his hip bones." 159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these fndings are potental manifestatons of which of the following? a. Nicotne withdrawal b. Heroin intoxicaton c. Alcohol withdrawal d. Amphetamine intoxicaton 160. A nurse is assessing an older adult client who had a stroke. Which of the following fndings should the nurse recognize as an indicaton of dysphagia? a. Abnormal movements of the mouth b. Inability to stand without assistance c. Paralysis of the right arm d. Loss of appette 161. *A nurse is providing preoperatve teaching to a client who will use PCA morphine sulfate following surgery. Which of the following informaton should the nurse include? a. The client should notfy the nurse when administering a dose of the medicaton. b. The client can administer a dose of medicaton every 6 to 8 min. c. The client should be cautous to avoid overmedicaton (OD). d. Family members can administer a dose the client. 18 of 47162. A nurse is assistng the provider with a paracentesis for a client who has ascites. Following collecton of the specimen, which of the following actons should the nurse take next a. Document the procedure. b. Measure the drainage. c. Record the color of the drainage. d. Label the specimen. 163. A nurse is caring for a client in an inpatent facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actons should the nurse take? a. Notfy security to monitor the facility exits. b. Place the client in seclusion. c. Inform the client of the risks involved if she leaves. d. Call the provider for a discharge prescripton. 164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunizaton to a child. Which of the following is a contraindicaton for administraton? a. Recent blood transfusion b. Allergy to penicillin c. Minor acute illness d. Low-grade fever 165. A nurse is preparing to administer 2.5 mL of medicaton intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? a. Ventrogluteal b. Dorsogluteal c. Vastus lateralis d. Rectus femoris 166. A nurse is teaching a female client how to reduce the risk of urinary tract infectons (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? a. Wearing underwear with a coton crotch b. Wiping from front to back c. Using perfumed toilet paper d. Urinatng immediately afer intercourse 167. A nurse is providing discharge instructons for a client who has a new prescripton for furosemide. Which of the following client statements indicates a need for further teaching? a. "I will take my morning pills with food or milk." b. "I will weigh myself every day." c. "I will notfy the nurse if I have muscle cramps." d. "I will limit my intake of fsh." 168. A nurse is caring for a client who has a prescripton for atorvastatn. Which of the following client conditons is a contraindicaton to this medicaton? a. hepatts C b. peptc ulcer disease c. bronchits d. chrohn’s disease 169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actons should the nurse include in the plan of care? a. Encourage a diet high in calcium. b. Provide a diet high in potassium. c. Ensure increased fluid intake. d. Restrict protein intake to the RDA. 170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actons should the nurse take frst? a. Take vital signs. b. Assess lochia. 19 of 47c. Massage the fundus. d. Give oxytocin IV bolus. 171. A nurse is caring for a client who is receiving intermitent enteral tube feedings. Which of the following interventons should the nurse perform a. Give 100 mL of water with every feeding. b. Obtain gastric residuals every 24 hr. c. Positon the head of bed at 30 degrees during feeding. d. Mix the clients medicatons with the tube feedings. 172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydraton. Which of the following assessment fndings indicates treatment has been effectve? a. Skin turgor displays tentng b. Flat anterior fontanel c. Cool, motled skin d. hyperpnea 173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiaton therapy. Which of the following should the nurse include in the teaching? a. Remove dye markings afer each radiaton treatment. b. Apply a warm compress to the irradiated site. c. Wear clothing over the area of radiaton treatment. d. Use a washcloth to bathe the treatment area. 174. A nurse in a provider's ofce is providing educaton to a client who is 16 weeks of gestaton and has a new prescripton for ferrous sulfate. Which of the following instructons should the nurse provide a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medicaton is effectve." b. "Take your iron medicaton with fluids other than coffee or tea." c. "It is important to take your iron medicaton on a full stomach." d. "If you miss a dose one day, take two doses the next day." 175. 175 A nurse receives a change-of-shif report on four clients. Based on the shif report informaton, which of the following clients should the nurse plan to assess a. A client who had a hip arthroplasty reports pain and erythema in his calf b. A client who has anorexia and peripheral edema c. A client who has Addison's disease with a blood glucose level of 75 mg/dL d. A client who had a barium enema 2 days ago and reports constpaton 176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medicatons should the nurse administer? a. Albuterol sulfate b. Hydromorphone c. Diphenhydramine d. Amitriptyline 177. A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actons should the nurse take? a. Ask the assistve personnel to assist the client in signing consent for treatment b. Ask the child to interpret for the client. c. Ascertain what language the client speaks and get an interpreter. d. Try to fnd an adult relatve to help the client communicate. 178. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontnues the magnesium sulfate afer the client displays toxicity. Which of the following actons should the nurse take? a. Positon the client supine. b. Prepare an IV bolus of dextrose 5% in water c. Administer calcium gluconate IV. d. Administer methylergonovine IM. 20 of 47179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The frst day of the clients last period was October. What is the expected delivery date? (Provide the date using four numerals, the frst two for the month and the second two for the day. For example, January 2 0102) a. 0711 (July 7, 2011) Formula: +1 year, -3 months, +7 days 180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess frst? a. A client who is scheduled for chemotherapy and has a hemoglobin of 9 b. A client who is 24 hr postoperatve following a transurethral resecton of the prostate (TURP) and has small blood clots in the urinary catheter c. A client who is receiving a blood transfusion and reports low-back pain d. A client who has a new colostomy with a reddish-pink stoma A nurse is planning care for a client who has a new diagnosis of HIV. I can’t seem to gain any weight Disaster triage following a natural disaster A client who has agonal respirations Client reports chest pain. Which of the following laboratory findings indicates myocardial damage Troponin I 1.8 ng/mL Child who has pediculosis capitis Store nonwashable items in plastic bags for 14 days Child who is unresponsive and has increased intracranial pressure Pad the side rails of the bed Client who is 8 hr postoperative following a right-modified radical mastectomy Coughing, frothy, pink secretions Newborn nursery is performing assessments on four neonates that are all less than 24 hr old pinna below the outer canthus of the eye Several client measurements were obtained with morning vital signs A 4-year old who has closed head injury and heart rate of 60 Tetralogy of fallot Pulse oximeter Medical unit received change-of-shift report 68 year old Recovering from an acute myocardial infarction. left sided heart failure Bilateral lung crackles Nutritional assessment on a client who has a calcium deficiency 21 of 47Osteogenesis Involuntarily admitted to the psychiatric unit following a failed suicide attempt experimental treatment Witness consent before medication administration Education to the mother of a toddler who has pertussis ...Answer missing……check it? Offer small amounts of fluid, frequently; monitor for airway obstruction School nurse scabies Red itchy papules on child’s groin area Diabetes insipidus DI severe head injury Urine output 250 ml 2 hr postoperative following an ileal conduit procedure bladder cancer Dusky colored stoma Mastitis of left breast does this mean that I must stop nursing my baby No, you can continue to nurse from both your breasts Orthopedic floor is completing the morning assessments on several clients 24-year old male who has a casted femur fracture Morning laboratory values to several clients Client who is prescribed digoxin and furosemide Education about electroconvulsive therapy ECT major depressive disorder General anesthetic administered prior to ECT treatments Charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant 60 year old who is recovering from shingles Nurse is teaching a client who has left-leg weakness how to use a standard walker Moves the left leg and walker ahead together Diagnosis of antisocial personality disorder Poor impulse control Home health nurse is reviewing treatment goals with a client who has diabetes mellitus evaluate laboratory tests to determine effective long-term management of blood glucose levels HbA1c Haloperidol for the treatment of schizophrenia Screen the client for tardive dyskinesia 22 of 47Urinalysis done for a preschool age child Pyelonephritis Delegates the following tasks to the assistive personnel bathe four clients distribute fresh water obtain morning vital signs Set a clear time frame for the completion of each task Hearing impairment incorporate which communication methods Rephrase sentences the client does not understand A nurse is discussing the z-track hydroxyzine hydrochloride with a newly licensed nurse This technique decrease risk of subcutaneous infiltration A nurse is reviewing medical records for four clients. Which of the following represents appropriate documentation Lovenox 30mg SC every 12 hr Performing postmortem care on an older adult client Place absorbent pads under the buttocks area Discussing a living will with a client It communicates my wishes for end of life care Benefit from a three-way indwelling catheter Prone to development of blood clots in the urine Dietary intervention for a client who is immobile due to pelvic and femur fractures Provide a high-protein diet If something happens to me from which I cannot recover, I don't want to go on a ventilator You're concerned that something may go wrong? Rising number of sexually transmitted infections in the community Brainstorming session with nurses Neutropenia Remove fresh flowers from the clients room Hyperthyroidism which of the following rooms is appropriate for the nurse to assign this client A room near the nurses station Experiencing acute mania Provide high-calorie nutritional supplements Ileal conduit due to treatment for bladder cancer Rinse the reusable pouch with hot water Adolescent who has cystic fibrosis and has a prescription for pancrealipase 23 of 47Take w meals A nurse is planning to provide community education about viral hepatitis Clients who have a history of viral hepatitis are unable to donate blood Ap reports to the nurse that another Ap has spent the entire morning on the phone and has not completed the morning assignment Redirect the AP to discuss the issue with the other AP A nurse is caring for a client who is receiving enteral nutrition A poor skin turgor Adolescent client who is in her third trimester of pregnancy Postpartum depression Client recovering from a closed head injury assumes a decerebate posture in reponse to stimuli D lying flat, not curved backwards little bastard Referral for a speech language pathologist Client who has difficulty swallowing Prescribed furosemide Rales in lower lobes of lungs OR increasing oliguria A nurse is admitting an infant who has bacterial meningitis Minimize environmental stimuli Laboratory data on a client who has dehydration Elevated blood urea nitrogen A nurse is caring for a client who has cirrhosis of the liver Monitor for abdominal ascites Difficulty falling asleep at night Eat a bedtime snack containing carbohydrates Perform wound irrigation for a client who has an open secondary wound when creating a sterile field Place the lid of a bottle of sterile solution within the sterile field Laboratory values on a client who has taken an overdose of acetaminophen organ damage Alanine aminotransferase ALT Nulliparous and in the first stage of labor the last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. at the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Check the FHR 24 of 47Health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field. IDK – Pupillary constriction – Fixate and follow a bright light or toy Providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation Iron Nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize A client who reports substernal chest pain A nurse is writing a plan of care for a client who is homebound and has stage 2 alzheimer's disease. Which of the following should the nurse include in the plan of care? Assist with money management Nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time aPTT of 100 seconds Turn off the heparin drip A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? Notify your provider if you experience muscle weakness A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy Place the newborn 45cm or 18 in from the light source A nurse is providing teaching for a client who has a new prescription for lithium carbonate You should take this medication on an empty stomach A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? Reading quietly in the room A nurse is teaching a client who has low-literacy level about home management of diabetes mellitus Show the client an educational video A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection Allow the sibling to visit after donning a sterile gown, mask, and gloves, but prohibit physical contact. 25 of 47A nurse working in an impatient mental health facility observes a client who is agitated and threatening staff members in the day room Accompany the client away from the common area A client asks the nurse if it is safe for him to take a glucosamine supplement Shellfish allergy After evaluating the morning laboratory results on several clients, the provider writes prescriptions for four clients assigned to the nurse's care Infuse 10 mEQ/l potassium chloride IV over 1 hr to a client who has a potassium of 3.2 meq/l A nurse is caring for a client following insertion of a subclavian non-tunnleed percutaneous central venous catheter CVC. Review the chest x-ray report A nurse is assessing a client who is 2 hr postoperative following insertion of a chest tube connected to a chest drainage system as depicted in the diagram above Fluctuation of the fluid level in chamber b (middle) A nurse is assessing a client with schizophrenia Auditory hallucinations A nurse is admitting a client who has chronic gout Allopurinol A nurse in a mental health clinic is reviewing the history and physical for a 17-year old client who has a new diagnosis of social phobia The client reports minimal alteration in performance at a part-time job A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr Blood is backing up in the IV tubing A nurse manager is presenting an in service for newly licensed nurses about advance directives Advanced directives must be notarized to be legally implemented A nurse at the family planning clinic triages several clients over the phone A client who uses diaphragm for contraception and has lost 30lb in the past 6 months dieting A nurse is teaching a family about home hospice care Hospice care improves the quality of life through palliative care Client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg Realign the extremity in traction At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports 26 of 47Indigestion A nurse is planning to change the dressings on a school-age child who has sustained multiple burns Apply the dressings in a proximal to distal pattern Correct way is to wrap distal to proximal Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 weeks after sustaining a mild concussion. EEG Explain that the client may not have coffee prior to the EEG A nurse is caring for a mother who was prescribed methadone during pregnancy Tachypnea Irritability tremors A nurse is assessing a client who is postoperative following abdominal surgery. I feel like my incision ripped open Place the client in low-fowlers position A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis Apply venous plexus foot pumps Preparing to administer eye drops to a client Use aseptic technique and drop the medication into the conjunctival sac Client who is receiving a controlled epidural analgesia infusion Covering the insertion site with a transparent dressing Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration Prepare the client for a caesarian section A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Ask the charge nurse to assign an experienced nurse to act as a resource A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office An infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, "am I dying"? Administer pain medication 27 of 47A nurse notices smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety Notify the facility operator Providing postoperative teaching to a client who has a newly inserted pacemaker I will use my cellphone on the ear opposite of my pacemaker Reviewing data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child abuse A 3-month old infant who has a skull fracture from reportedly rolling off the changing table Preparing to obtain informed consent for a colonoscopy from a client who does not speak English. Provide a consent form in the client's spoken language A nurse is providing teaching to the parent of a preschooler who was newly diagnosed with a latex allergy Bananas Obsessive compulsive disorder OCD Teach the client to meditate about obsessive thoughts Client who has just given birth to a stillborn newborn Acknowledging the reality of the newborns death In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard? A computer chair with wheels Recognizes that the teen pregnancy rate in the community has increased. Arrange a meeting with teenage mothers who are high school students in the community Reviewing medications for a group of clients labor and delivery Phenytoin for seizure disorder Client following an open coletomy Uncontrolled pain Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea Administer an antiemetic Client who reports the use of chondroitin and glucosamine Improve joint functioning 28 of 47Recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling The tubing may be kinked A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC Hepatitis A Discharge teaching about disease prevention to a client who has active tuberculosis Educating the client how to cover nose and mouth with tissues when coughing Gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor Contractions occur every 90 seconds Postpartum unit is caring for several clients A client who is 4 days postpartum and has lochia serosa Infection control nurse is reviewing care procedures for four clients A client who has varicella zoster is placed in a negative pressure room Creating an activity plan for a home-bound older adult client. in the planning, the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process Decreased blood oxygenation Immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule Reduces the respiratory rate Administer an injection to a client when the client states "I don't want that injection. The last time I got that I was sore for a week Battery A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take? Report to the nurse manager Nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease GERD Sleep with the head of the bed elevated 29 of 47A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility A client who has an abdominal wound and is receiving negative-pressure wound therapy Preparing a client for surgery and has just administered the preoperative injection Raise the side rails on the bed Home health nurse is admitting a client who is prescribed peritoneal dialysis. Clarify the clients actual and perceived health needs A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents Swallowing sounds are audible stools are yellow and seedy after 7 days maternal breasts become soft following feedings Caring for a client who has a new prescription for chlorpromazine by IM injection Check orthostatic pressure 1 hour after administration Nurse educator is discussing modes of transmission with nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission West nile virus from a mosquito bite Nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit. A client who is 2 days postoperative following a colon resection Inpatient psychiatric unit is setting short-term goals for an adolescent who was admitted for treatment of anorexia nervosa The client will develop a personalized meal plan Nurse is caring for a client who will be receiving a transfusion of platelets Decrease in bleeding from puncture sites Nurse in an emergency department is assessing a client who has a nasal fracture. Clear fluid drainage from the nares Nurse Manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Nurse should pad the bony prominences. Provider’s prescription should include the type of restraint to use Nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24 hr following surgery, the nurse should instruct the client to do which of the following. Intermittently place ice on the ankle 30 of 47Admitting a client to the medical-surgical unit. Which of the following actions should the nurse first take? Observe the client's level of mobility Nurse is admitting an unidentified female who was brought to the emergency department. 3 months An emergency department nurse triages a group of school children injured in a school bus crash A child who reports diplopia and nausea and was unconscious at the scene but is now awake Nurse in a provider’s office is caring for a client who has Parkinson's disease and has been taking levodopa for the past 5 weeks. The client reports a new onset of muscle twitching This is a manifestation of drug toxicity and may require a dosage reduction. After making morning rounds, the charge nurse on a surgical unit delegates the following tasks to the assistive personnel AP Set up a room for an expected postoperative admission A nurse in a pediatric unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions? Pertussis A client has just returned to the nursing unit following cardiac catheterization. In the immediate post procedure period, which of the following is the priority nursing action? Immobilizing the affected extremity Providing dietary teaching for a client who has a history of nephrolithiasis which of the following is appropriate to include in the teaching? Avoid foods that have high levels of oxalates A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two minor children and a limited support system. Ask the client about her understanding of the diagnosis Assessing a client who has systemic lupus erythematous SLE which of the following is an expected finding? Dry, raised facial rash A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? Remind the client to place the cane on the unaffected side A nurse is caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the assistive personnel AP 31 of 47Transfer a client from bed to chair with mechanical lift Provide postmortem care on a client who experienced cardiac arrest Discussing care with a newly licensed nurse for a client who practices orthodox Judaism Roast beef and ice cream Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house Review the effects of secondhand smoke with family members A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic Determine the clients living situation A nurse is preparing the auscultate a client's apical pulse at the point of maximal impulse PMI Fifth intercostal space at the left midclavicular line A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65ml/hr through a gastrostomy tube The client is lying in a supine position A nurse is caring for a client who is receiving IV antibiotics and tests positive for clostridium difficile C. difficile c diff Place the client on contact precautions An older adult client tells the nurse, "I thought immunizations were for kids." the nurse informs the client that older adults should receive which of the following immunizations Herpes zoster vaccine A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125ml/hr. Which of the following actions should the nurse plan to take? Dilute the solution prior to the infusion A nurse in the emergency department is caring for a client following a motor-vehicle crash. Stabilize the cervical spine Charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. 32 of 47A 10-year old who has pneumonia and is receiving respiratory treatments. A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse Flushed IV w 0.9% sodium chloride or pain relieved by position change Nurse plans to ambulate a client on the third day after cardiac surgery. Pre-medicate the client with the prescribed analgesic A nurse is reviewing the history and physical of a client who has right ventricular heart failure Confusion Primagravida client in the emergency department at 12 weeks of gestation hyperemesis gravidarum 1000ml/hr A nurse is electronically documenting assessment findings for a client. The client reports a pain level of 6 on a scale from 0-10 Nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father’s do-not-resuscitate request. Tell me your feelings about your father’s prognosis A home-health nurse is providing teaching about self administration of insulin to a client who is newly diagnosed with diabetes mellitus I can use the same area as long as I rotate injection sites A nurse in the post anesthesia care unit is caring for four postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients Thyroidectomy A nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago. Support the affected leg on a pillow. A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity Tinnitus A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Keep a 3-foot distance from the radiation implant 33 of 47A nurse is caring for a client who has atypical depression and is taking phenelzine. Low-fat yogurt A nurse is planning care for a client who is comatose and has stage II decubitus ulcer on the coccyx Provide the client with an alternating pressure mattress A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit C looks normal but lots of artifact or fibs in between QRS's A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids. You're curious why I am interested in you and not the others? A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections UTI Empty the bladder before and after intercourse A nurse is caring for a client who has heart failure and has started taking a loop diuretic Decreased reflexes A nurse is caring for a client who is postoperative and at risk for development of deepvein-thrombosis DVT Prolonged bed rest A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate? Idk – Kidney fxn (BUN/Cr) or Na+ level or Thyroid level or CBC, or Calcium A nurse delegates tasks to a licensed practical nurse LPN and an assistive personnel AP. when admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate to delegate to the LPN Insert an indwelling catheter if the client has not voided in 3 hr. A nurse is caring for a client who has just returned to the unit following a bronchoscopy Offers oral fluids to the client 34 of 47A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all the new employees to screen for the presence of tuberculosis? Mantoux test A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? Let's talk about what happened to you A nurse is caring for an infant who is being treated for dehydration Flat anterior fontanel A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nurse demonstrates veracity The nurse explains the potential risks of treatment A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications Graft-versus-host disease 2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source 3 an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60 5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first? Arrange a meeting with teenage mothers who are high school students in the community 6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first? Place an NPO sign on the door of a client scheduled surgery 7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate? Covering insertion site with a transparent dressing 8 A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? A client who has agonal respirations 9 A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? Series of four hepatitis vaccines is recommended to prevent viral hepatitis 10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity? The nurse explains the potential risks of treatment 11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the client’s wishes. The nurse committed which of the following? Battery 35 of 4712 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure? Bilateral lung crackles 13//// 14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients? A client who has difficulty swallowing 15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? A general anesthetic is administered prior to ECT treatments 16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome Tachypnea/irritability/tremors 17 A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? Hyperemesis 18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Which of the following actions is appropriate for nurse to take? Ask the charge nurse to assign an experienced nurse to act as a resource 19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time? Allow the sibling to wave at the client through the window or door 20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150 mL per hr. prior to starting the infusion, which of the following actions should the nurse take? Review the chest x-ray report 21 A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrealipase. Which of the following should the nurse include in the teaching? Take with meals 22 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose? Alanine aminotransferase (ALT) 23 A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)? A 24-year-old male who has a casted femur fracture 24 A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father’s do-not-resuscitate request. Which of the following is a therapeutic response by the nurse? “Tell me your feelings about your father’s prognosis” 25 A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex allergy. The nurse should discuss that a cross reaction may occur with which of the following foods? Bananas 26 A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is appropriate for the nurse to assignment client to? A room with a temperature of 20 degrees (68f) 27 A nurse has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? Monitoring the insertion site for infection 36 of 4728 A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicate the treatment is effective? Flat anterior fontanel 29 A nurse is reviewing medical for four clients. Which of the following represents appropriate documentation? Carafate 1 g PO 1 hr ac 30 A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse, “does this mean that I must stop nursing my baby?” which of the following is an appropriate statement by the nurse? “No, you can continue to nurse from both your breasts.” 31 A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “why did you choose to talk to me out of this room full of kids?” which of the following responses by the nurse is therapeutic? “you’re curious why I am interested in you and not the other?” 32 A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room. Which of the following actions should the nurse take first? Accompany the client away from the common area 33 A client who is precepting a nursing student is brings the following client observation to the nurse’s attention. Which of the following client should the nurse assess first? A client who is 3 days postoperative colectomy with a large, loose melena stool 34 A nurse is planning teaching for a client who is at 10 weeks gestation and has a history of urinary tract infections (UTIs). Which of the following information should the nurse plan to include in the teaching about UTI prevention? Empty the bladder before and after intercourse 35 A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24 hr following injury, the nurse should instruct the client to do which of the following? Intermittently place ice on the ankle 36 After evaluating the morning laboratory results on several clients, the provider writes prescriptions for four clients assigned to the nurse’s care. Which of the following prescriptions is the nurse’s highest priority? Administer vitamin K 10 mg IM to a client on warfarin with and INR of 6 37 a nurse is caring for a client who has ruptured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds. Which of the following should the nurse take first? Turn off the heparin drip 38 A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Exaggerate lip movements 39 A nurse is reviewing morning values of several clients. Which of the following findings is the highest priority for the nurse to report to the provider? A client who is prescribed digoxin and furosemide and has a potassium level of 3.1 mEq/L 40 A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action? Check orthostatic blood pressure 1 hr after administration 41 A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deepvein thrombosis? Apply venous plexus foot pumps 42 A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? Taking a daily walk on the hospital grounds 37 of 4743 A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? Hold the bottle of sterile solution with the palm over the label while pouring 44 A nurse is reviewing the history and physical on a client who has right ventricular heart failure. Which of the following is an associated finding? Elevated pulmonary artery pressure 45 A nurse is assessing a client who has schizophrenia. Which of the following findings indicates a risk for selfharm? Auditory hallucinations 46 A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? “I’ll use my cell phone on the ear opposite of my pacemaker.” 47 A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox Judaism. Which of the following meal suggestions by the newly licensed nurse indicates a need for further teaching? Carrot sticks and cottage cheese 48 A nurse is preparing to auscultate a client’s apical pulse at the point of maximal impulse (PMI). The nurse should place the diaphragm of the stethoscope at which of the following locations? Fifth intercostal space at the left midclavicular line 49 A charge nurse in the emergency department is reviewing the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibly of child abuse? A 9-month-old infant who is dressed inappropriately for the current weather conditions 50 A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? Remind the client to place the cane on the unaffected side 51 A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation? Calcium 52 A nurse in the postanesthesia care unit is caring for four postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients. A client who had a thyroidectomy 53 A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse initiate first? Demonstrate how to perform the procedure 54 A visiting nurse is writing a plan of care for a client who is homebound and has stage 2 Alzheimer’s disease. Which of the following should the nurse include in the plan of care? Educate family about loss of family recognition 55 A nurse suspects another nurse is chemically impaired during the shift. Which of the following is an appropriate action for the nurse to take? Report to the nurse manager 56 A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125 mL/hr. Which of the following actions should the nurse plan to take? Dilute the solution prior to infusion 57 A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? The infusion pump for administering continuous feeding is turned off. 58 A nurse is admitting an unidentified female infant who was brought to the emergency department. Based on the assessment findings, the nurse should estimate the infant’s age to be which of the following? 38 of 476 months 59 A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? Have the client tilt her head slightly so that the medication enters the nasolacrimal duct 60 A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? Improve joint functioning 61 A nurse is performing a nutritional assessment on a client who has a calcium deficiency. The nurse should identify that the client is at risk for which of the following? Tetany 62 A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding? Dry, raised facial rash 63 A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognized as the priority finding? Coughing frothy, pink secretions 64 A nurse in a provider’s office is caring or a client who has Parkinson’s disease and has been taking levodopa for the past 5 weeks. The client reports a new onset of muscle twitching. Which of the following statements by the nurse is appropriate? “This is a manifestation of drug toxicity and may require a dosage reduction.” 65 A nurse in the labor and delivery unit is receiving medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? Phenytoin for seizure disorder 66 A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? Educating the client how to cover nose and mouth with tissue when coughing 67 A nurse is planning care for a client who has neutropenia. Which of the following nursing interventions is appropriate to include in the care plan? Remove fresh flowers from the client’s room. 68 A nurse is planning to change the dressing on a school age child who has sustained multiple burns. Which of the following actions should the nurse plan to take? Apply the dressing in a proximal to distal pattern 69 An older adult client tells the nurse,” I thought immunizations were for kids.” The nurse informs the client that older adults should receive which of the following immunizations? Herpes zoster vaccine 70 a nurse is caring for a client who was involuntarily admitted to the psychiatric unit following a failed suicide attempt. The provider prescribes a medication that is part of an experimental treatment. Which of the following actions should the nurse take? Exclude the client from the study due to involuntary admission 71 A nurse analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? Elevated blood urea nitrogen 72 a community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first? Determine the client’s living situation 73 a nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? Jugular vein distention 39 of 4774 A nurse is assessing a client who is preparing for surgery. The client tells the nurse, “If something happens to me from which I cannot recover don’t want to go on a ventilator.” Which of the following is an appropriate response by the nurse? “You’re concerned that something may go wrong?” 75 A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? “has you partner physically hurt you before?” 76 A nurse is caring for a client who reports pain. Which of the following laboratory findings indicates myocardial damage? Troponin I 1.8ng/mL 77 a nurse is caring for a client who is prescribed furosemide. The nurse understands this medication is used to treat which of the following client conditions? Rales in lower lobes of lungs 78 A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community of which of the following is to generate new ideas to address the public health concern? A brainstorming session with nurses 79 a nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter? A female client who is prone to development of blood clots in the urine 80 A nurse manager is presenting information to the nursing staff regarding the appropriate use of the client restraints. Which of the following should the nurse include? The nurse should pad the bony prominences/ The nurse should remove the restraints every 2hrs/ The provider’s prescription should include the type of restraints to use 81 A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to eh facility. Which of the following clients should the nurse recommend for discharge? A client who is 1-day postoperative laparoscopic cholecystectomy whose temperature is 37.7 C. 82 A nurse is admitting a client who has chronic gout. The nurse anticipates which of the following provider prescriptions? Allopurinol 83. A nurse is caring for a client who is 2 days postoperative following a lumber laminectomy and is reporting nausea. Which of the following actions should the nurse take first? Administer an antiemetic 84. A nurse in the recovery room is a client who has a new tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify these finding as resulting from which of the following? Tubing may be kinked 85. A nurse is planning for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the assistive personnel AP? Measure I&O for a client who is receiving peritoneal dialysis Transfer the client from bed to chair with mechanical lift provide postmortem care on a client who experienced cardiac arrest 86. An assistive personnel (AP) at a long-term care facility reports to the nurse that another AP has spent the entire morning on the phone and has not completed the morning assignment. Which of the following is an appropriate action by the nurse? Ask the AP what work remains to be completed on the assignment 87. A community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house. Which of the following is a priority intervention? Suggest smoking cessation strategies to family members 88. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included? 40 of 47Newborn swallowing sounds are audible while breastfeeding Newborns’ stools are yellow and seedy after 7 days of breastfeeding Maternal breasts become soft following feedings 89. A nurse is caring for a client who will be having a transfusion of platelets. The nurse recognizes that the ___ outcome of ____ will be which of the following? Decrease in bleeding from puncture sites 90. A nurse in a prenatal clinic is caring for an adolescent client is now in her third trimester of pregnancy. The nurse identifies that the client is at an increased risk for the which of the following? Postpartum depression 91. A nurse is planning dietary intervention for a client who is immobile due to pelvic and femur fractures. Which of the following should the nurse include in the plan? Provide a high-protein diet 92. A home health nurse is providing teaching about self-administration of insulin to a client who is newly diagnosed with DM. Which of the following statements by the client a need for further teaching? I will gently massage the injection site following administration 93. A school nurse is assessing a child who has scabies. Which of the following is an expected finding? Red, itchy papules on the child’s groin area 94. A nurse is caring for a client who is postoperative and at risk for development of DVT. Which of the following should the nurse identify as increasing the risk of developing venous stasis? Prolonged bed rest 95. A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding? Constipation 96. A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize ___ this desquamation as an indication of which of the following complications? Graft-versus-host disease 97. A nurse is providing education to the mother of a toddler who has pertussis. which of the following statements by the parent indicates the teaching has been effective? If I get pregnant, I should check with my provider about receiving a pertussis booster. 98. A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding 99. A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? pertussis 100. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? Pulse oximeter 101. A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? Observe the client’s level of mobility 102. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A 10-year-old client who has pneumonia and is receiving respiratory treatments 103. A nurse in a residential mental health facility is planning care for a new client who has OCD. Which of the following is appropriate for the nurse to include in the plan of care? Gradually decrease the time allowed for ritualistic behavior 41 of 47104. A nurse delegates tasks to an LPN and AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? Measure the amount of gastric drainage every 2 hr. 105. A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching? cleanse the skin around the stoma with a moisturizing soap 106. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions by the nurse is appropriate? Monitor for abdominal ascites 107. A nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following information should be included in the teaching? Store non-washable items in plastic bags for 14 days 108. A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the following actions by the client indicates a need for further teaching? Places the walker 2 feet forward with each step 109. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel AP requires the nurse to intervene? Offers oral fluids to the client 110. A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder cancer. For which of the following finding should the nurse notify the provider? A dusky-colored stoma 111. A nurse is providing teaching for the parents of a school-age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, “We are unable to say anything to convince him that ___ is impossible.” Which of the following is an appropriate suggestion? Encourage the child to be involved with the soccer team as the coach’s assistant or team manger 112. A nurse is taking care of a client who has a diagnosis of HIV. Which of the following client statement should the nurse address first? I am lonely because I don't have anyone to talk to you. 113. A nurse is caring for a client who has I left femur fracture is a skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following action is appropriate by the nurse? Increase the amount of traction 114. A nurse educator is discussing about modes of transmission with nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission? Transmission of West Nile Virus from a mosquito bite 115. A nurse is creating an activity plan for a home-bound older adult client. In the planning the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process. Which of the following age-related physiologic changes should the nurse consider in the plan? Decreased blood oxygenation 116. An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? A child who reports diplopia and nausea and was unconscious at the scene but is now awake 117. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? premedicate the client with the prescribed analgesic 42 of 47118. A nurse is electronically documenting assessment findings for a client. Which of the following is an example of subjective data? The client reports a pain level of 6 on a scale from 0 to 10 119. A nurse notice smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? Close the fire doors on the unit 120. A nurse is caring for a client who has a diagnosis of antisocial personality disorder. The nurse should expect the client to demonstrate which of the following? Poor impulse control 121. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 in in duration. Which of the following actions should the nurse take? Prepare the client for a cesarean section 122. A nurse is planning care for a child who is unresponsive and increased ICP. Which of the following actions should the nurse take? Pad the side rails of the bed 123. A nurse is planning care for a client who takes haloperidol ___ the treatment of schizophrenia. Which of the following should the nurse include in the plan of care? Screen the client for tardive dyskinesia 124. A nurse is caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, “Am I dying?” Which of the following actions should the nurse take first? Obtain a pulse oximetry reading 125. A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? Tinnitus 126. A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurses to facilitate the client’s grief process? Acknowledging the reality of the newborn’s death 127. A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include in the teaching? Sleep with the head of bed elevated 128. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurse to offer as an evening snack? Low fat yogurt 129. A nurse is admitting an infant who has bacterial meningitis. Which of the following actions should the nurse take first? Administer cefazolin 130. A client asks the nurse if it is safe for him to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? Shellfish allergy 131. A nurse is analyzing the cardiac rhythms of four telemetry clients in the coronary care unit. Identify the rhythm strip that the nurse should recognize as indicative of a client who should be receiving warfarin. rhythm C 132. A nurse in a postpartum unit is caring for several clients. After receiving a change of shifassess first? A client who is 3 days postpartum and has not had a bowel movement since prior to admission 133. A nurse is teaching a family about hospice care. Which of the following appropriate for the nurse to include in the teaching? Hospice care encourages the family to coordinate health care services 43 of 47134. An infection control nurse is reviewing care procedures for four clients. Which of the following requires the nurse to intervene? A client who has pulmonary TB is placed in a positive pressure room. 135. A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Urine output of 250ml/hr 136. A nurse is providing teaching for the client who has a new prescription for lithium carbonate. Which of the following should the nurse include the teaching? Diarrhea is an indication of toxicity. 137. A nurse is caring for a client who is receiving a blood transfusion at 125ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride IV 138. A nurse is caring for an adolescent client who has no previous history of a seizure disorder___ admitted after having a 3-minn tonic-clonic seizure 2 weeks after sustaining a mild concussion. The client is scheduled to have an electroencephalogram (EEG) in the morning. For breakfast, the client orders coffee and a donut. Which of the following nursing actions is appropriate at this time? Explain that the client may not have coffee prior the EEG 139. At the beginning of the ____ shift, a team leader delegates the following tasks to the assistive personnel (AP) have four clients, distribute fresh water and obtain the morning vital signs. At noon, the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future? Set a clear time from for the completion of each task 140. A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care? Provide the client with an alternating pressure mattress 141. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? Raise the side rails on the bed 142. A nurse is performing postmortem care on an older adult client. Which of the following action is appropriate to take? Lower the head of the bed to a supine position 143. A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following actions should the nurse take first? Stabilize the cervical spine 144. A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of TB? Mantoux test 145. A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize? A client who has a Glasgow Coma Score of 4 146. A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings? Pinna below the outer canthus of the eye 147. A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? Restrict dietary calcium intake 44 of 47148. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following suggestions should the nurse recommend? Eat a bedtime snack containing carbohydrates 149. An immunity health nurse is planning to make home visits to several clients who all live within a few miles’ radius of the office. Which of the following clients should the nurse plan to visit first? A legally blind client who has diabetes mellitus and whose insulin syringes need to be prefilled for the coming week. 150. A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? “Notify your provider if you experience muscle weakness.” 151. A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. difficle. Which of the following action by the nurse is appropriate? Place the client on contact precautions 152. A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo 153. A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set? The client will develop a personalized meal plan. 154. A nurse is caring for a preschool-age child who has a short leg, plaster cast applied 1 hr ago. Which of the following is an appropriate interventions? Support the affected leg on a pillow. 156. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? Consistent contractions last 80 seconds. 157. A home health nurse is reviewing treatment goals with a client who has DM. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? HbA1C 158. A nurse is preparing to obtain informed consent for a colonoscopy from a client who does not speak English. Which of the following actions should the nurse take? Ask the health care interpreter to explain the procedure 159. A nurse manger is presenting an inservice for newly licensed nurses about advance directives. Which of the following statements by a new nurse indicates a need for further teaching? “Advanced directives must be notarized to be legally implemented.” 160. A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? “It communicates y wishes for end-of-life care.” 161. A home health nurse is doing an in-home assessment for an older adult client who is at risk for falls. which of the following assessment findings should the nurse identify as a potential hazard for the client? Electrical cords secured to the baseboards 162. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? Clear fluid drainage from the nares 163. A nurse documents that a client recovering from a closed head injury assumes a decerebrate posture in response to stimuli. Which of the following illustrations indicates this client’s positioning? Posture D 45 of 47164. A nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse to the postpartum unit? A client who is 2 days postoperative following a colon resection 165. A nurse is caring for a client who has a newly implanted sealed internal radiation devices to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? Maintain the client on bed rest for 72 hr. 166. During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following? Decreases the level of anxiety 168. At the start of the evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Constipation 169. A nurse is discussing the Z-track administration of hydroxyzine hydrochloride with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? “This technique decreases the risk of subcutaneous infiltration.” 170. A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plain of care? Provide high-calorie nutritional supplements. 171. A nurse is evaluating the results of the above urinalysis done for a preschool age child. The nurse should identify that these findings are consistent with which of the following renal disorders? Large albumin Nephrotic syndrome 172. A nurse is preparing to administer vancomycin to a client who has as infected wound. The nurse should plan to __ for which of the following adverse reactions? Ototoxicity 173. A nurse is teaching a client who has a low-literacy level about home management of diabetic mellitus. Which of the following actions is appropriate? Show the client an educational video. 174. A nurse is assessing a client who is 2 hr postoperative following insertion of a chest tube connected to a chest drainage system as depicted in the program above. Which of the following is an expected finding? Fluctuation of the fluid level in chamber “b” 175. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer, the client has two minor children and a limited support system. Which of the following is the priority nursing action? Inform the client of available community resources. 176. A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include? Pain relieved by position change 177. A nurse in a mental health clinic is reviewing the history and physical for a 17-year old client who has a new diagnosis of social phobia. Which of the following is an expected finding? The client reports minimal alteration in performance at a part time job. 178. A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr. Which of the following assessment finding indicates to the nurse that the IV sire needs to be changed? The area around the IV sire is reddened. 179. A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering ___ dose, which of the following laboratory values should the nurse evaluate? Thyroid hormones 180. A nurse is assessing a client who is postoperative3 following abdominal surgery. The client states, “I feel like my incision ripped open,” The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? Place the client in low-Fowler’s position. 46 of 47A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse