Rn Comprehensive Online Practice 2019 A new updated practice exam complete questions and answers graded A solution

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Rn Comprehensive Online Practice 2019 A new updated practice exam complete questions and answers graded A solution 1. A nurse is performing tracheostomy care for a client who is postoperative follow ... ing a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway? Withdraw the catheter if the client begins coughing. Apply suction for 10 seconds. Advance the catheter 2 cm (0.8 in) after resistance is met. Use medical asepsis when performing the procedure. 2. A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Teach the client reportable adverse effects from the medication. Check the insulin dose with another licensed nurse Administer the insulin at a 90° angle. Clean the insertion site. 3. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? Urine output 120 mL in 4 hr Systolic blood pressure 12 mm Hg lower than the preoperative level Audible stridor Normal sinus rhythm with an occasional premature ventricular contraction 4. A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.6 5. A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? Choosing to donate organs can delay the timing of the child's funeral. The family can have the child an open casket without fearing that the organ donation might disfigure the childs body The family should understand that an autopsy is mandatory prior to organ donation. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death. 6. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff 's acceptance of this change, which of the following actions should the nurse manager take first? Provide information about scheduling issues to the staff Ask staff members to participate in a trial of the new scheduling system. Encourage staff to offer alternate scheduling solutions.
 Develop goals to implement the new scheduling system. 7. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? Bradycardia Low back pain Hypertension Distended jugular veins 8. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure Floating dark spots Decreased central vision Double vision 9. A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? Report of persistent constipation Hgb 14 g/dL Albumin 4.2 g/dL Recent weight loss 10. A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? "This type of nutrition is more effective than eating by mouth." “You will receive fingersticks for blood glucose testing. "TPN is a way to provide vitamins and minerals without increased calories." "Taking TPN can increase the risk of developing a latex allergy." 11. A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fuid volume de deficit? Shortness of breath Visual disturbances Decreased BUN levels •Orthostatic hypotension 12. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate Assist the client to a knee-chest position.
 Prepare the client for continuous internal monitoring. Prepare for an emergency cesarean birth. 13. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? Initiate the referral at the time of discharge. Have the client contact a physical therapist when feeling ready to begin therapy. Verify that insurance will pay for outpatient physical therapy. •Involve the client in selection of a physical therapy provider. 14. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? Diminished reflexes Hematuria Hyperglycemia Hearing loss 15. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? "I will make sure my 4-year-old child wears a helmet when using a skateboard." "I should have my child avoid sun exposure between 10 am and 2 pm." 
"I can give my 2-year-old child a whole hotdog on a bun." 
"When my infant is in the carrier, I will place it on a raised, at surface whenever possible." 16. A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first? A client who has a temperature of 38.2° C (100.8° F) and requests a cup of ice chips A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10 A client who has voided and is ready for a bladder scan
 A client who is confused and has been attempting to get out of bed 17. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority? Lethargy Confusion Polyuria 
Fine hand tremors 18. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place Contact the triage officer. Implement the client tracking system. 
Ask the communications officer to release a press statement. Notify the incident commander. 19. A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? Notify the provider if a thrill is palpated at the fistula. Auscultate the affected extremity for a bruit Discourage range-of-motion exercises in the affected extremity. Perform venipuncture in the affected extremity. 20. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? "There's a protocol for reviewing your medical record, and I can initiate the process." "The medical record has a lot of medical terminology, and it might be di cult for you to understand." "You should really talk to your provider if you have any questions about your treatment." "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see." 21. A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? Weight loss Urinary retention Hypertension Hypoglycemia 22. A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 23. A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? Lethargy Diaphoresis Bradycardia Cough 24. A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? "You will need to draft a health care proxy so a designee can make this decision for you." "I will make sure that no one performs any lifesaving measures if your heart stops." "Your provider determines if you should have lifesaving measures if your heart stops." "I will provide you with information about medical treatment to include in your living will." 25. A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? Give an antiemetic 30 min after medication administration. Monitor blood glucose levels. Monitor for tumor lysis syndrome. Maintain hydration with liberal fluid intake 26. A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? Uric acid crystals Protein WBCs Nitrites 27. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. Dampen the skin before applying the skin barrier and ostomy pouch. Place the skin barrier over the stoma and hold it for 30 seconds Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma. 28. A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? Flush the clients gastrostomy tube with 30 ml of water before administering the medication. Crush the client's medications and mix them in with the tube feeding formula prior to administration. Change the client's feeding bag every 72 hr.
 Administer multiple prescribed medications at the same time. 29. A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? The client needs assistance when transferring from the bed to a wheelchair. The client will have a visit by a home health nurse tomorrow.
 The client's partner will bring clothes for the client to change into prior to discharge. The client often needs encouragement to engage in personal hygiene activities. 30. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching? Liver Oranges Chicken Red wine 31. An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? Collection of a stool specimen Preparation of a client's postoperative bed Preparation of a teaching plan about pneumonia Insertion of a nasogastric tube 32. A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? Contact Droplet 
Airborne
 Protective environment 33. A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take? Instill chilled lavage solution into the client's NG tube. Attach the client's NG tube to low intermittent suction. Use 0.9% sodium chloride for irrigation of the NG tube. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time. 34. A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? Install a raised toilet seat at home. Maintain the hip at an angle greater than 90°. Minimize the use of a walker.
 Place a pillow under the knees when lying down. 35. A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? Amylase Troponin T 
Low-density lipoprotein (LDL) Homocysteine 36. A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? "Will my husband be able to continue as the executor of his parents' estate?" "One of my husband's coworkers visited last week to tell me my husband might lose his job." "Do you think it is necessary to postpone our daughter's wedding until my husband is feeling better?" "My husband doesn't know that I've already moved out of the house and led for a divorce." 37. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? Assist the client with contacting individuals from the client's support system. Give the client information about available community resources for shelter. Suggest the client obtain mental health counseling. Determine the client's perception of the personal impact of the crisis. 38. An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? Uses a draw sheet to move the client to the left side of the bed Raises the total height of the bed to waist level Places a pillow under the client's right arm Lowers the side rails on the left side of the bed 39. A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A client who is alert and has a 2.5 cm (1 in) laceration on the forehead A client who has significant head trauma and agonal respirations. A client who has an open fracture of the right forearm
 A client who is unconscious and has a rapid, thready radial pulse 40. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement? Airborne Droplet Contact Protective environment 41. A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? 1 medium raw carrot 1/2 cup cooked spinach 
1/2 cup cooked butternut squash 1 cup sliced cantaloupe 42. A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? Ask for help with a two-person assist transfer. Assess the client for functional limitations Request a mechanical lift device. Medicate the client for pain. 43. A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? "You should leave your glasses o throughout the testing." "You should stand 15 feet away from the chart."
 "You should get three symbols on a line correct to pass the line." "You should keep both eyes open during the testing." 44. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruption placentae. Which of the following findings should the nurse expect? Persistent uterine contractions Bright red vaginal bleeding Hyperactive deep-tendon re exes Fundal height of 40 cm 45. A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? Butter y rash over the cheeks and nose Report of pain in the joints of the lower extremities Blanching of the fingers and toes Scaly patches over the knees and elbows 46. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? Inject 20 units of air into the NPH insulin vial . Shake the NPH insulin vial vigorously to mix the insulin.
 Use a new needle to draw up the insulin from the second vial. Draw the longer-acting insulin into the syringe first. 47. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? Encourage friends and family to visit the child. Withhold administering the varicella vaccine to the child. Collect a daily urine specimen from the child to check for proteinuria. Provide a low-protein diet for the child. 48. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique? Open the top outer flap of the package toward the body. Clean the penis with the nondominant hand. 
Don sterile gloves after opening the lubricant packet. • Set the catheter tray on the overbed table at waist height. 49. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding? The newborn nurses every 4 hr during the day and sleeps through the night. The newborn has six to eight wet diapers per day. The newborn's current weight is 3.18 kg (7 lb). The newborn has sticky, greenish stools. 50. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? A client who is pregnant and has cytomegalovirus (CMV) An adolescent client who has foodborne botulism A child who has erythema infectiosum
 A young adult client who has herpes simplex virus type 1 (HSV-1) 51. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? Provide an opportunity for the client to express their feelings. Move the client to a quiet place away from others. State expectations that set limits on the client's behavior. Administer a PRN dose of haloperidol to calm the client. 52. A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? Spinal manipulation Acupuncture Therapeutic touch Guided imagery 53. A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings A client who was admitted for dehydration and is receiving a continuous IV infusion A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation 54. A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? Displacement Regression Suppression Sublimation 55. A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? Decreased blood pressure Increased cardiac output Increased oral temperature Decreased lung expansion 56. A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? Ask the client to rate their pain level. Assist the client in changing positions. Administer a PRN analgesic medication. Explain the importance of early ambulation. 57. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? "I should report a change in the color of my stools." "I can take acetaminophen to treat a headache."
 "I will take a calcium supplement while taking this medication." "I will return in a month to have my blood tested." 58. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? "Place your baby's car seat at a 30-degree angle." "Your baby's car seat should be rear-facing until he is 6 months old." "Swaddle your baby in a light blanket before placing him in the car seat." "Secure the retainer clip at the level of your baby's armpits." 59. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? Tell the client to self-report to the state health department. Require that the client speak with a public health nurse. Explain to the client why this information will be shared. Refer the client to a social worker for counseling. 60. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal. Give the infant 240 mL (8 oz) of juice per day. Introduce new foods one at a time over 5 to 7 days. Give whole milk first, then small amounts of solid food. 61. A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? Constipation Nausea Wheezing Muscle rigidity 62. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Intermittent cramping Moderate lochia rubra Boggy uterus
 Perineal edema 63. A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? "Your mother might still know you are here." "Why do you feel that way?" "It seems like you feel your visits are a waste of time." "Are you sure you would not want to see your mother again?" 64. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? Maintain the client on bed rest. Restrict the client to 1 L of fluid per day.
 Place cool compresses on the edematous area. Elevate the a effected leg. 65. A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care? Give the client a choice of foods and beverages. Supervise the client during and after eating.
 Encourage casual conversation about food during meal times. Provide opportunities for the client to choose their own meal times. 66. A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? "I should avoid eating smoked meat, cheeses, and ripe avocados while taking this type of medication." "I should watch for common reactions like dry mouth and constipation." "I will be at increased risk for high blood pressure while taking this medication." "I will take my daily dose of this medication every morning before breakfast." 67. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? Informs the provider about a client's suicide plan Notifes the health department of a client's diagnosis of chlamydia Reports suspected child maltreatment to social services Tells the hospital chaplain a client's diagnosis 68. A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect? "I have not had any food cravings." "The spotting I was having has stopped." "I don't feel depressed anymore." "I have not vomited as much recently." 69. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Investigate environmental factors that might be contributing to client injury during these hours. Review the performance evaluations of nurses who work during these hours.
 Implement a plan to transition from team nursing to primary care nursing during these hours. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours. 70. A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? Measure the client's vital signs. Reposition the client.
 Encourage the client to use an incentive spirometer. Administer pain medication. 71. A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? Pain level Neurologic status Laboratory results Urinary output 72. A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? An RN who is monitoring a client who started receiving a blood transfusion 5 min ago An assistive personnel (AP) who just began performing a bed bath
 A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client An assistive personnel (AP) who is assisting a client to return to bed 73. A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? Keep the client resting in bed. Ask the client to restate directions. 
Clear objects from the client's walking area. Evaluate the client's ability to swallow. 74. A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? "I should administer the ear drops as soon as I remove them from the refrigerator." "I should pull the top of the ear upward and back while instilling the medication." "I should massage behind the ear after I instill the drops." "I should have my child lie on the a effected side for a few minutes after I put the drops in the ear." 75. A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? Wheezes Tachycardia Restlessness Substernal pain 76. A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take? Ask the caller for verification of their identity. Give the caller limited information about the client.
 Transfer the phone call to the client's room. 
Inform the caller that they should obtain permission from the client's provider. 77. A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? Muscle spasms of the affected extremity A pain rating of 6 on a scale from 0 to 10 Upper chest petechiae Ecchymosis over the fractured area 78. A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses' actions. Advise the nurses that they are being insubordinate. Tell the nurses to stop the discussion.
 Document the incident in the client's medical record. 79. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? Lack of remorse Sensitivity to rejection Extreme mood swings Self-mutilating behavior 80. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual. Use a diagram to explain the procedure to the nurse. Demonstrate the procedure to the nurse.
 Ask the nurse about their knowledge of the procedure. 81. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? The client reports leg itching under the cast around the mid-upper thigh area. The client reports increased pain when the leg is lowered below the level of the heart. The client's cast became wet during a sponge bath. 
The client's heel is reddened and tender. 82. A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? Increased bowel sounds Dry, sticky mucous membranes Decreased deep tendon reflexes Numbness and tingling of the extremities 83. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? Administer oxygen. Initiate an infusion of oxytocin. Massage the uterus to expel clots. Obtain a CBC. 84. A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? Ensure that the staff nurse changes the dressing. Notify the nurse manager.
 Complete an incident report.
 Gather more information about the staff nurse's actions. 85. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? "Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner." "Let's go on that family vacation we've got planned. We will deal with this when we return." "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." "This isn't possible. Just last week the doctor said that the cancer was responding well to treatment." 86. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? Temperature 39.4° C (102.9° F) Headache Constipation Dry mouth 87. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? •Use hydrogen peroxide to clean kitchen surfaces. Seal non washable items in a plastic bag for 2 weeks. Wear a surgical mask when in public. 
Limit family visits to 30 min periods. 88. A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? Compare the nurse's time management skills to the skills of coworkers. Review client satisfaction reports about the nurse's performance.
 Ask another staff nurse to evaluate the nurse's time management skills. Maintain regular notes about the nurse's time management skills. 89. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A 90. A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Abdominal striae Masklike face Nystagmus - Ptosis 91. A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO3- 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? Uncompensated metabolic acidosis Uncompensated respiratory acidosis Compensated respiratory acidosis Compensated metabolic acidosis 92. A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding Potassium deficiency Infection Hyperbilirubinemia 93. A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? Include chicken broth in the toddler's diet. Feed the toddler the BRAT diet. 
Initiate oral rehydration therapy for the toddler. Offer the toddler flavored gelatin. 94. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply.) Nystagmus Facial flushing Diplopia
 Nasal congestion Headache 95. A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? "When the lesions no longer itch." "Three days after the lesions appeared." "When crusts have formed on every lesion." "When the lesions disappear." 96. A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? "Estrogen levels decrease during pregnancy, causing the stool to become hardened." "Decreased water absorption in the intestine during pregnancy causes constipation." "The intestine absorbs iron less efficiently during pregnancy, leading to constipation." "The enlarged uterus compresses the intestines and causes constipation." 97. A nurse is initiating discharge planning for a client who had a stroke and is experiencing right- sided weakness. Which of the following actions should the nurse take first? Ask a social worker to identify the client's insurance eligibility for rehabilitation services. Request a referral for the client to receive physical therapy.
 Arrange for the delivery of prescribed medications to the client's home. Provide the client with a list of community resources. 98. A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure-sensitive valve. Which of the following information should the nurse include in the teaching? "You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly." • "You should keep the catheter clamped when not in use."
 "You should swim twice weekly to prevent tissue from adhering to the cu ." "You should change your dressing every 10 days." 99. A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? (Click on the audio button to listen to the clip.) Clang association Echolalia Neologisms Word salad 100. A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into child's mouth. Place the child in a side-lying position.
 Administer rescue breaths until the seizure subsides. Obtain an ECG during the seizure. 101. A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following actions should the nurse plan to take? Allow the plasma to warm for 30 min before transfusion. Confirm the client's identification by checking the room number. Enter the plasma product number into the client's medical record. Administer each unit of plasma over 4 hr. 102. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? Mark the edges of stairs for contrast. Cover exposed extension cords with throw rugs. 
Use 40-watt bulbs in lighting fixtures.
 Instruct the client to obtain vison testing once every other year. 103. A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (Select all that apply.) "A speech pathologist will be performing a swallowing study for you." "You should rest before eating a meal."
 "You should restrict foods that are high in vitamin D." "Reduce your intake of dietary fiber."
 "Thicken your beverages before drinking." 104. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? Dry the newborn. Assign the first Apgar score to the newborn. Place an identification bracelet on the newborn. Obtain the newborn's weight. 105. A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? "I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature." "I will clean my toothbrush in my dishwasher once each month."
 "I will take my temperature once each week and let my doctor know if it is high." "I will walk for short distances throughout the day." 106. A nurse is assessing a client who has delirium. Which of the following g manifestations should the nurse expect? Projective blame Excessive clinging Rapid Speech Social Awkwardness 107. A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? Decreased activity Hemoptysis 275 mL/24 hr Fever Weight loss 2.3 kg (5 lb) 108. A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? Ketonuria Fecal impaction Latex allergy Tachycardia 109. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? "I can resume my daily aspirin therapy." "I will contact my provider if my eye feels itchy." "I will bend at my knees when picking an object up off the floor." "It's okay for me to pick up my grandchild who weighs 20 pounds." 110. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? Identify health-related issues within the community. Develop measurable health goals for community residents. Create safety education classes for the program. Enlist volunteers from the rural community to promote the program. 111. A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? Carotid bruit Tracheal deviation Pulsus paradoxus Heart murmur 112. A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? BP 150/87 mm Hg WBC count 2,800/mm3 Auditory hallucinations Nausea 113. A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? Avoid venipunctures when possible. Restrict visitors to family members. Limit oral fluid intake to between meals. Prohibit fresh flowers in the client's room. 114. When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? Coloring with crayons in a coloring book Deep breathing and "going limp as a rag doll" Blowing bubbles with liquid soap to "blow the hurt away" Taking a warm bath and playing with a bath toy 115. A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? The client's partner tells the nurse that the client understands the procedure. The nurse locates the provider's prescription for the surgical procedure. The nurse witnesses the provider's explanation of the procedure. The client is able to accurately describe the upcoming procedure 116. A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1-Remove the inner cannula. 2-Remove the soiled dressing. 3-Clean the stoma with 0.9% sodium chloride irrigation. 4- Change the tracheostomy collar. 117. A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals? A client who has Alzheimer's disease and is demonstrating aphasia A client who has asthma and an increased respiratory rate A client who had a stroke and is to start oral intake A client who had diabetic ketoacidosis and is difficult to rouse 118. A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicates an understanding of the teaching? "We will let our child watch a favorite video before bed." "We should read a story together every night before bedtime." "We can let our child fall asleep in our room, and then move to her to her own bed." "We should change the bedtime to be an hour later." 119. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? Administer the TPN solution at the same rate using manual drip tubing. Offer the client oral fluids in place of the TPN solution. Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr 120. A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? Fever unresponsive to antipyretics Pain in weight-bearing joints Decreased heart rate Peeling of the soles of the feet 121. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? Contractions will be felt primarily in the upper abdomen. The cervix transitions to an anterior position. Contraction intensity decreases with ambulation. The cervix progressively thickens. 122. A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. The newly licensed nurse uses a penlight to assess for changes in the contour of the body. The newly licensed nurse uses the dorsal surface of the hand to assess skin temperature. 123. A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? Stroke the infant's cheek. Depress the infant's tongue. Turn the infant's head to one side. Tap on the bridge of the infant's nose. 124. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? Naloxone Flumazenil Acetylcysteine Atropine 125. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? Check the client's temperature every 2 hr. Initiate fall precautions for the client. Monitor the client's urine for discoloration. Limit the client's fluid intake to 1 L per day. 126. A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? Encourage the parents to bring toys from home. Use a visual analog scale to rate the toddler's pain. Inform the toddler about the procedure 1 week before hospitalization. Stress to the parents the need for maintaining the hospital's daily routine. 127. A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? Document the client's refusal of the medication. Administer the medication that the provider prescribed. Request consent from the client's family to administer the medication. Administer an oral dose of the medication. 128. A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? Muscle damage Partial-thickness skin loss Visible subcutaneous tissue Tendon exposure 129. A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? "Set your hot water heater temperature at or below 120 degrees Fahrenheit." "Cover your baby with a light blanket while sleeping." "Make sure the slats on the baby's crib are no more than 3 inches apart." "Place your baby's car seat rear-facing until the age of 1 year old." 130. A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? Encourage the client's problem-solving abilities. Discuss the client's previous experience with loss. Promote the client's self-esteem. Establish the termination date of therapy. 131. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? Popcorn Diced steamed carrots Whole celery sticks Marshmallows 132. A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A client's IV pump delivers an inadequate dose of medication. A nurse follows a client's advance directives and discontinues enteral feedings. A nurse discards unused, expired bags of IV fluids. A client refuses an IV bolus of pain medication. 133. A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Obtain the client's blood pressure before the nurse administers medication. Initiate a referral with a dietitian for the client. Inform the client about the adverse effects of the medication. Recommend a salt substitute to the client. 134. A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies." Which of the following actions should the nurse take? (Select all that apply.) Refer the client to a community-based social worker. Initiate a consult with a home health care provider. Provide the client with information about the American Red Cross. Postpone the discharge until someone can stay with the client. Give the client information about local support groups 135. A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? Document the actual time of medication administration. Notify the risk manager. Complete an incident report. Inform the nurse manager of the issue 136. A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? Apply an over-the-counter cream if the wound becomes infected. Clean the wound twice a day with povidone-iodine. Apply heat to the wound for 10 min, four times per day. Double-bag soiled dressings in plastic bags for disposal. 137. A nurse is caring for a client who vomits on a reusable BP cu. Which of the following actions should the nurse take? Place the BP cu in a labeled bag to send it for decontamination. Immediately rinse the BP cu in hot running water. Dispose of the contaminated BP cu in the bag lining the trash can. Clean the BP cu with a chlorine bleach solution. 138. A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? Increase intake of fluids and fiber to prevent constipation. Complete a serum pregnancy test before taking the medication. This medication coats stomach ulcers so that they can heal. Take a magnesium-containing antacid along with this medication. 139. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? Slightly blue hands and feet Respiratory rate 40/min Axillary temperature 36.2° C (97.2° F) Apical pulse 136/min 140. A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? Remove the client's restraints while sleeping. Document the client's status every 60 min. Check for a new prescription every 6 hr. Provide a staff member to stay with the client continuously 141. A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? "If you suspect you are pregnant, stop taking this medication." "You cannot become physically dependent on this medication." "Sedation is a common adverse effect of this medication." "If you forget a dose, you can double your next dose." 142. A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use? • 143. A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? Allow the newborn to breastfeed temporarily. Relieve pressure by expressing milk daily. Place ice packs on the breasts for 15 min several times per day. Sleep with a loose-fitting bra to prevent nipple stimulation. 144. A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Instills 100 mL of air into the NG tube after checking for residual Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr Adds 20 mL of blue dye to each feeding to help detect aspiration Keeps the head of the bed elevated to 45° for 1 hr after feedings 145. A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? Hypersensitivity to criticism Fears of abandonment Grandiose delusions Reclusive behavior 146. A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? Offer a referral to the client for social services. Develop a safety plan with the client. Encourage the client to reach out to family and friends. Provide the client with a list of support groups. 147. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? Hypotension Headaches Bruising Oliguria 148. A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? "You don't need advance directives now because you are competent and can make decisions for yourself." "You must wait for a period of 6 months after your diagnosis before initiating advance directives." "You will have to speak to an expert who works in the social service department." "You should complete advance directives in the event you cannot express your own wishes." 149. A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage? perform a rapid needs assessment 150. A nurse has 4 patients. What should the nurse delegate to the AP for meals? alzheimers w/ aphasia [Show More]

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