Exit Exam 757 Questions And Answers (100% Correct Elaborations) 2023

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? A. The client wants to talk about the diagnosis with ...

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? A. The client wants to talk about the diagnosis with the nursing staff. B. The client has a decreased energy level. C. The client makes funeral arrangements. D. The client requests a second opinion. B. The client has a decreased energy level. A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply.) A. Allows the nurse to touch him on the arm B. Plays with toys in the examining room C. Answers questions asked by the nurse D. Makes eye contact with the nurse E. Sits on his parent's lap when the nurse enters the room A. Allows the nurse to touch him on the arm C. Answers questions asked by the nurse D. Makes eye contact with the nurse A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first? A. A client who has bipolar disorder and is displaying flight of ideas B. A client who has ADHD and has an inability to concentrate C. A client who has schizophrenia and is having command hallucinations D. A client who has depressive disorder and is withdrawn C. A client who has schizophrenia and is having command hallucinations A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make? A. "I'll take him back to the nursery, so you can get some rest." B. "Babies need to cry soon after they are born to develop their lungs." C. "Let me show you how to swaddle and cuddle him, then you try." D. "If I turn him on his side, maybe he'll go back to sleep." C. "Let me show you how to swaddle and cuddle him, then you try." A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take? A. Take the first drop of blood that forms after the puncture B. Wear sterile gloves C. Keep the finger in a dependent position D. Select the central tip of the finger C. Keep the finger in a dependent position A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel? A. Docusate sodium B. Ranitidine C. Vitamin D3 D. Naproxen D. Naproxen clopidogrel is a platelet inhibitor and naproxen is a NSAID that can cause GI ulcers that bleed A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first? A. Administer opioid pain medication. B. Apply an ice pack to the affected extremity. C. Check for pain with passive movement of the affected extremity. D. Elevate the affected extremity with several pillows. C. Check for pain with passive movement of the affected extremity. A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? A. Decreased hemoglobin B. Somnolence C. Bradycardia D. Decreased blood pressure B. Somnolence A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the staff can medicate a client against his will, without a court hearing, in which of the following situations? A. A client who has a serious mental illness B. A client who is having difficulty making decisions about his treatment C. A client for whom the benefits of the medication outweigh the risks D. A client who is attempting to hurt himself or others D. A client who is attempting to hurt himself or others A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching? A. "Monitor for muscle weakness while taking the medication." B. "Rotate injection sites when administering the medication." C. "Withhold the medication if your pulse rate is above 100 beats per minute." D. "Increase your intake of dietary fiber to increase absorption." A. "Monitor for muscle weakness while taking the medication." A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? A. A nurse from another unit after a client commits suicide B. A social worker is assigned to an involuntary committed school-age client C. A client's partner after the client reports intimate partner abuse D. A client's employer who is concerned about safety due to substance use B. A social worker is assigned to an involuntary committed school-age client A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Hgb 13.2 g/dL B. Urine protein 3+ C. Fasting blood glucose 72 mg/dL D. BUN 15 mg/dL B. Urine protein 3+ Normal range for hemoglobin in a female are 12-16 g/dL, normal BUN is 10-20 mg/dL A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse's priority, requiring immediate intervention? A. Pain rating of 9 on a scale from 0-10 B. Blood pressure 160/90 mm Hg C. Oxygen saturation 89% D. Abdominal dressing with a moderate amount of bright red drainage C. Oxygen saturation 89% A nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately? A. A 2 kg (4.4 lb) weight gain B. Blurred vision C. Potassium 3.5 mEq/L D. Resumption of cigarette smoking B. Blurred vision Normal serum potassium is 3.5-5 mEq/L A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first? A. Place the client on bed rest B. Obtain the client's ABG levels C. Prepare the client for a ventilation-perfusion scan D. Elevate the head of the client's bed D. Elevate the head of the client's bed A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management? A. Urine ketones B. Glucose tolerance test C. Glycosylated hemoglobin D. Fasting blood glucose C. Glycosylated hemoglobin A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene? A. Requests a client to assist with distributing lunch trays B. Tells a client he will lose his phone privileges if he does not take his medication C. Encourages a client to participate in a recreational therapy group D. Places mechanical restraints on a client who is hitting another staff member B. Tells a client he will lose his phone privileges if he does not take his medication A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room? A. Oral suction equipment B. Wrist restraints C. Tongue depressor D. Tracheostomy tray A. Oral suction equipment A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate? A. "You should avoid crossing your legs for 3 months." B. "You should avoid putting a pillow between your legs when in bed." C. "You should avoid exercising for the next 6 weeks." D. "You should avoid lying on your right side." A. "You should avoid crossing your legs for 3 months." A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching? A. Drink 240 mL (8 oz) of water with each meal B. Eat a small meal every 2-3 hr C. Avoid eating dairy products D. Choose foods that are high in fat B. Eat a small meal every 2-3 hr A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching? A. "I have to remain upright for 1 hour after taking the medication." B. "I should take this medication in the morning and at night." C. "I should expect my tongue to turn black after I take this medication." D. "I have to take this medication on an empty stomach." B. "I should take this medication in the morning and at night." A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include? A. Airborne B. Droplet C. Protective D. Contact A. Airborne A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? A. "Self-administer oxygen through your nasal cannula at 6 mL per minute during meals." B. "Perform pulmonary hygiene 1 hour before meals." C. "Drink at least 240 mL of water during each meal." D. "Lie down for 30 minutes after eating." B. "Perform pulmonary hygiene 1 hour before meals." A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? A. Decreased sodium excretion B. Improved absorption of vitamin B12 C. Improved respiratory function D. Reduced fat in the stools D. Reduced fat in the stools A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? A. "Why do you feel the staff is the FBI?" B. "What makes you think the staff is following you?" C. "The psychiatric staff is not FBI. They are here to help you." D. "This must be very frightening for you. Let's talk more about it." C. "The psychiatric staff is not FBI. They are here to help you." A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take? A. Clean the pin insertion sites on a daily basis B. Ensure that the weights are hanging freely C. Apply a 9 kg (20 lb) weight to the traction D. Remove the weights while the client is eating B. Ensure that the weights are hanging freely A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings? A. Calcium level 8.0 mg/dL B. Peripheral vascular disease C. Taking anticoagulant medication D. IV access on the same extremity B. Peripheral vascular disease A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma? Lady with eyes closed with nodule on eyelid A nurse is assisting with the admission of a client who has Vancomycin-resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client? A. Contact precautions B. Droplet precautions C. Airborne precautions D. Protective precautions A. Contact precautions A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take? A. Use a 12 point font size B. Present information from complex to simple C. Explain medical terminology using basic, one-syllable words D. Write the information at an 8th-grade reading level C. Explain medical terminology using basic, one-syllable words A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority? A. "I'm angry with my girlfriend about an argument we had last night." B. "I have anxiety when I'm in a large group." C. "I'm not sleeping much because of all the homework I have." D. "I would rather be alone than with my friends." D. "I would rather be alone than with my friends." A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel. Which of the following types of wound dressings should the nurse use? A. Gauze packing B. Calcium alginate C. Transparent film D. Adhesive strips C. Transparent film A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current blood pressure is 114/55 mm Hg. Which of the following actions should the nurse take? A. Request a prescription for a different pain medication for the client B. Administer the medication to the client C. Place the client on strict bedrest D. Repeat the client's blood pressure measurement B. Administer the medication to the client A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plans? (Select all that apply.) A. Set a specific time frame for meeting performance goals B. Ask the nurse supervisor to review the plan C. Base performance goals on peer comments D. Request clients complete an evaluation about the AP's quality of care E. Include the performance standard that the AP should meet A. Set a specific time frame for meeting performance goals B. Ask the nurse supervisor to review the plan E. Include the performance standard that the AP should meet A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? A. Cleanse the neck by rubbing with a washcloth B. Limit fluid intake to 750 mL per day C. Eat three large meals each day D. Avoid exposing the neck to the cold D. Avoid exposing the neck to the cold A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement? A. Create a schedule with an assistive personnel to do hourly rounding for the client B. Apply rubber-soled slippers before ambulation C. Move the bedside table with the client's personal items close to the bed D. Determine the client's ability to use the call light D. Determine the client's ability to use the call light A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? A. "You cannot drink fluids for 4 hours after the procedure." B. "You will need to urinate before the procedure." C. "You will have a leg bag to collect the urine." D. "You will feel pressure when I inflate the catheter balloon." B. "You will need to urinate before the procedure." A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take? A. Meet with the client's family to discuss treatment options B. Perform a mental status examination to establish the client's competency C. Ask the client if he has any financial concerns D. Talk with the nurse about the need to support the client's decision D. Talk with the nurse about the need to support the client's decision A nurse is reinforcing teaching about breastfeeding with a client who gave birth 2 days ago. Which of the following information should the nurse include? A. Allow the newborn to nurse for no more than 10 min on each breast B. Store expressed breast milk in the refrigerator for up to 72 hr C. Feed the newborn 8-12 times every 24 hr D. Supplement feedings with 30 mL (1 oz) of water four times per day C. Feed the newborn 8-12 times every 24 hr A nurse is assisting with the admission of a school-aged child. Which of the following actions should the nurse plan to take? A. Initiate contact precautions for the child B. Place the child on bed rest for 24-48 hr C. Restrict the child's intake of foods containing vitamin K D. Keep the child on NPO status for 8 hr A. Initiate contact precautions for the child A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? A. Keep the client's daily protein intake below 0.8 g/kg B. Position the client supine with his legs elevated C. Measure the client's abdominal girth daily D. Restrict the client's sodium intake to 3 g per day C. Measure the client's abdominal girth daily A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? A. Apple juice B. Ice cream C. Coffee D. Yogurt D. Yogurt A nurse is assisting with the care of a client who has increased intracranial pressure following a closed head injury. Which of the following actions should the nurse take? A. Monitor the client's temperature every 4 hr B. Wake the client every 6-8 hr C. Elevate the head of the bed to 30 degrees D. Place the client in lateral Sim's position C. Elevate the head of the bed to 30 degrees A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care? A. Administer diuretics B. Limit fluid intake C. Apply support stockings D. Place on bedrest C. Apply support stockings A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend? A. Remind the client of the day and time often B. Alternate daily caregivers C. Avoid discussing the client's fears D. Offer the client several choices at mealtimes A. Remind the client of the day and time often A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include? A. Potatoes B. Oranges C. Grapes D. Corn C. Grapes A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching? A. "You should have a sputum examination every 4 weeks." B. "You should obtain a chest x-ray every 3 months." C. "You should schedule a tuberculin skin test every 6 months." D. "You should stop taking your antituberculin medication after 2 weeks." A. "You should have a sputum examination every 4 weeks." A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? A. Explain that nonreactivity might require immediate medication administration B. Tell the client the test should take about 10 min C. Remind the client to press the button when she feels fetal movement D. Assist the client into a supine position C. Remind the client to press the button when she feels fetal movement A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include? A. Encourage socialization during meal times B. Elevate the head of the client's bed to 30 degrees C. Tilt the client's head forward during meals D. Provide three large meals per day C. Tilt the client's head forward during meals A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider? A. Leukorrhea B. Epistaxis C. Fatigue D. Persistent headache D. Persistent headache A nurse is talking with the partner of a client who recently died. Which of the following statements should the nurse make? A. "I will call the chaplain to speak to you." B. "It seems bad right now, but things will get better over time." C. "Tell me what I can do for you at this time." D. "I think you should attend a grief support group." C. "Tell me what I can do for you at this time." A nurse is assisting with the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light." Which of the following is an inappropriate response by the nurse? A. "That must have been a difficult experience for you." B. "It will not happen this time because we have more staff." C. "I am sure no one meant to ignore you." D. "Let's discuss what brought you to the hospital this time." A. "That must have been a difficult experience for you." A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? A. Neisseria gonorrhoeae B. Sarcoptes scabiei C. Human papillomavirus D. Impetigo contagiosa A. Neisseria gonorrhoeae A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse suspect? A. Hematuria B. Nuchal rigidity C. Jaundice D. 2+ pedal edema B. Nuchal rigidity A nurse is reviewing laboratory findings for four clients. Which of the following laboratory values is an expected finding for a client who has end stage kidney disease? A. Creatinine 15 mg/dL B. Potassium 4.0 mEq/L C. BUN 15 mg/dL D. Phosphorus 4.0 mg/dL A. Creatinine 15 mg/dL Normal range of creatinine is 0.6-1.2 mg/dL for males and 0.5-1.1 mg/dL for females. Normal range of serum potassium is 3.5-5 mEq/L. Normal BUN is 10-20 mg/dL. Normal phosphorus is 3-4.5 mg/dL. A nurse is caring for a client who is taking warfarin and has an INR of 5.5 The nurse should expect which of the following instructions from the provider? A. Obtain an aPTT level B. Change the medication to heparin IV C. Administer protamine sulfate D. Reduce the dosage of the medication A. Obtain an aPTT level Normal INR is 0.8-1.1. A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess? A. Urine output of 360 mL/12 hr B. Blood pressure of 100/74 mm Hg C. Distended neck veins D. Decreased bowel sounds C. Distended neck veins A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching? A. "You should place the diaper over the strap of the harness." B. "You can apply lotion under the straps of the harness." C. "The harness can be removed for sleeping each night." D. "The harness can promote hip joint development." D. "The harness can promote hip joint development." A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3-4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error? A. Provider's progress notes B. Nursing care plan C. Incident report D. Controlled substance inventory record C. Incident report A nurse is preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take? A. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field B. Hold the irrigation solution bottle 5 cm (2 in) above the sterile container C. Place the irrigation solution bottle cap on the sterile field D. Open the outer wrapper of the sterile package toward her body A. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field A nurse begins to bathe a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following? A. Boundary crossing B. Countertransference C. Veracity D. Promoting trust B. Countertransference Countertransference is when you as the nurse transfer your feelings onto your client A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client? A. Contact precautions B. Airborne precautions C. Droplet precautions D. Protective environment A. Contact precautions A nurse is documenting client care in the nurse's notes and notices that a space was left blank. Which of the following actions should the nurse take? A. Draw a horizontal line through the space and sign at the end of the line B. Leave the space as it is within the entry C. Place the date at the beginning of the space, followed by double lines D. Black out the line with a felt-tip pen A. Draw a horizontal line through the space and sign at the end of the line A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill? A. Chlorhexidine B. Bleach C. Hydrogen peroxide D. Isopropyl alcohol B. Bleach A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the following findings should the nurse identify as a safety risk? A. The client's daughter fills the medication organizer once weekly B. The client's electrical wires are run under carpeting C. The client has a smoke detector in his bedroom D. The client has a raised toilet seat in his bedroom B. The client's electrical wires are run under carpeting A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching? A. "A family member must witness your signature on the informed consent form." B. "We require informed consent for all routine treatments." C. "You can sign the informed consent form after the provider explains the pros and cons of the procedure." D. "We can accept verbal consent unless the surgical procedure is an emergency." C. "You can sign the informed consent form after the provider explains the pros and cons of the procedure." A nurse is reinforcing teaching with a client who has a trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching? A. "You should expect your urine to turn brown." B. "You might develop constipation." C. "You will need to take the medication for 3 weeks." D. "You might have increased saliva production while taking this medication." A. "You should expect your urine to turn brown." A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take? A. Remind the client about the specifics of the procedure B. Explain to the client that the procedure will help treat his diagnosis C. Ask the client to sign the consent form anyway D. Notify the charge nurse about the situation D. Notify the charge nurse about the situation A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information? A. "Advance directives include a living will." B. "Federal legislation dictates the legal guidelines for advance directives." C. "My medical record should not include my advance directives." D. "Advance directives include instructions for resolving financial matters after my death." A. "Advance directives include a living will." A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend? A. Encourage the client to take frequent walks during the day B. Give the client a barbiturate medication at bedtime C. Allow the client to nap for at least 1 hr during the day D. Put a simple lock on the client's bedroom door A. Encourage the client to take frequent walks during the day A nurse is assisting in the care of a client who is 8 hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply.) A. Check the client's capillary refill B. Administer terbutaline 0.25 mg subcutaneous C. Give the client 800 mg of ibuprofen D. Massage the client's fundus E. Assist the client to empty her bladder E. Assist the client to empty her bladder A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage? A. "Apply steady pressure with this tennis ball to her sacral area." B. "Assist her to breathe in deeply at the beginning of each contraction." C. "Gently stroke her abdomen during contractions." D. "Help her to focus on an object in the room." C. "Gently stroke her abdomen during contractions." A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? A. Massage the area around the client's coccyx B. Limit the client's fluid intake C. Use a moisture barrier on the client's skin D. Clean the client's skin with soap and hot water C. Use a moisture barrier on the client's skin A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy? A. Be honest with the client about the prognosis B. Allow the client to choose treatment times C. Provide privacy during client care procedures D. Administer pain medication on a routine schedule B. Allow the client to choose treatment times A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? A. Turns a nitrazine strip blue B. Appears greenish-brown in color C. Preceded by bloody mucus D. Has a pH of 7 B. Appears greenish-brown in color A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? A. Administer opioids to the adolescent on a schedule B. Position the adolescent with his neck hyperextended C. Keep the adolescent NPO D. Inform the adolescent that he might experience a headache D. Inform the adolescent that he might experience a headache A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching? A. "I am not allowed to change my mind once I sign this document." B. "My partner needs to be present when I sign this document." C. "I should discuss this document with my family after I sign it." D. "An attorney will need to notarize this document for it to be valid." C. "I should discuss this document with my family after I sign it." A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take? A. Clamp the urinary catheter tubing B. Irrigate the bladder with 20-30 mL of 0.9% sodium chloride irrigation C. Replace the indwelling urinary catheter with a smaller diameter catheter D. Allow the tubing to hang below the drainage bag B. Irrigate the bladder with 20-30 mL of 0.9% sodium chloride irrigation A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? A. Instruct the client to remain as still as possible during the recording B. Assist the client to the orthopneic position C. Tell the client to expect a mild stinging sensation D. Attach a blood pressure cuff to the client's upper arm A. Instruct the client to remain as still as possible during the recording A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching? A. "You should increase fluid intake to relieve dysuria." B. "You will no longer be infectious once you have completed a course of antibiotics." C. "You should wear nylon underwear until the lesions have healed." D. "You should have the lesions drained as they appear." A. "You should increase fluid intake to relieve dysuria." A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of the following actions should the nurse plan to take? A. Apply sterile gloves prior to handling the drainage system B. Attach the drainage tube to low-intermittent suction C. Cleanse the drainage port with soap and warm water D. Compress the container before replacing the drainage plug D. Compress the container before replacing the drainage plug A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching? A. Administer the medication when the toddler has an acute asthma attack B. Mix the medication in juice prior to administration C. Provide an additional dose of the medication prior to physical activity D. Administer the medication to the toddler each evening D. Administer the medication to the toddler each evening A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship? A. Overcoming resistance B. Promoting insight C. Defining responsibilities D. Examining one's feelings C. Defining responsibilities A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate? Lower left A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Preoxygenates with 100% oxygen B. Suctions for 30 seconds C. Auscultates breath sounds D. Applies suction during catheter removal B. Suctions for 30 seconds A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client? A. Thrombocytopenia B. Dry cough C. Hypotension D. Hyperglycemia C. Hypotension atenolol is a beta-blocker used to decrease blood pressure and an adverse effect of nitroglycerin is hypotension A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse use to verify the client's identity? A. Verify the client's identity with a family member B. Ask the client the name of the facility C. Ask the client to state her first name D. Verify the client's identity using a photograph D. Verify the client's identity using a photograph A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should she report to the provider? A. "I do not use fabric softener when I wash my clothing." B. "I limit my time spent out in the sunlight." C. "I remove old medication on my skin before applying a new dose." D. "I try not to look at the scales on my body." D. "I try not to look at the scales on my body." A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls? A. Medication record B. Admission face sheet C. Pastoral care notes D. Social activities report A. Medication record A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? A. Evaluate the need to suction the airway of a client who has a new tracheostomy B. Inspect the incision of a client who is postoperative following a leg amputation C. Feed a client who has difficulty swallowing liquids following a stroke D. Complete post mortem care for a client who has died D. Complete post mortem care for a client who has died A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report? A. Hyperreflexia B. Skin rash with fever C. Tinnitus with ear pain D. Diplopia B. Skin rash with fever allopurinol is a uric acid reducer used to treat gout and kidney stones A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching? A. "I will instruct the client to sit when putting on a pair of pants." B. "I will instruct the client to sit in a low-rise chair." C. "I will instruct the client to wear socks when ambulating to the bathroom at night." D. "I will instruct the client to bend at the waist when picking up an object." A. "I will instruct the client to sit when putting on a pair of pants." A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge? A. A client who reports chest pain after ambulating B. A client who has atrial fibrillation and an INR of 4 C. A client who has a sodium level of 140 mEq/L after one episode of diarrhea D. A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf C. A client who has a sodium level of 140 mEq/L after one episode of diarrhea Normal serum sodium is 136-145 mEq/L A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? A. Obtain vital signs once per day B. Administer liquid supplements C. Weigh the client weekly D. Discuss food topics during mealtime B. Administer liquid supplements A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will delegate any tasks I do not have the skill to perform to an assistive personnel." B. "I will be protected from liability if I am appointed with a resource nurse when I float." C. "I will document in the medical record the support nurse who assists with planning care for my clients." D. "I am not liable if I perform delegated functions when supervision is not provided." C. "I will document in the medical record the support nurse who assists with planning care for my clients." A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? A. Serum creatinine 1.0 mg/dL B. Urine specific gravity 1.020 C. Urine output 12 mL/hr D. BUN 18 mg/dL C. Urine output 12 mL/hr Normal urine output is 30-50 mL/hr A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? A. Define the problem B. Identify data collection methods C. Perform chart audits D. Review the facility's policy and procedure manual B. Identify data collection methods A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? A. "Cover the electrical outlets with wet towels." B. "Turn on fans in the facility to circulate air." C. "Open the fireplace dampers in the day room." D. "Move clients to a room above ground with few windows." D. "Move clients to a room above ground with few windows." A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of the following actions should the nurse take? A. Give IV fluids through the AV shunt B. Obtain blood pressure from the right arm C. Check a bruit over the shunt on a regular basis D. Avoid range of motion in the right arm C. Check a bruit over the shunt on a regular basis A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting? A. Veracity B. Autonomy C. Justice D. Beneficence A. Veracity Veracity refers to being honest and truthful. A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? A. Dorsal recumbent B. Left lateral C. Semi-fowler's D. Supine C. Semi-fowler's A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching? A. "You should not palpate your child's abdomen prior to surgery." B. "You should give your child captopril 200 mg PO daily." C. "Your child should have surgery in 7-10 days to remove the tumor." D. "Your child will not require further treatment after removal of the tumor." A. "You should not palpate your child's abdomen prior to surgery." A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A. Place a pillow under the child's head B. Restrain the child's upper extremities C. Place a padded tongue blade in the child's mouth D. Turn the child onto his back A. Place a pillow under the child's head A nurse is contributing to the plan of care for a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend? A. Place the client in high-fowler's position during feedings B. Dilute the formula with water for the first 24 hr of therapy C. Check the client's gastric residual 15 min after each feeding D. Chill the formula before initiating feedings A. Place the client in high-fowler's position during feedings A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client's arms. This nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse's priority action? A. Provide information about moving to a shelter B. Offer support and create a safe, trusting environment C. Document the client's injury and include a photograph D. Determine if there is a gun in the client's home B. Offer support and create a safe, trusting environment A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect? A. Hypothermia B. Somnolence C. Muscle weakness D. Hallucinations D. Hallucinations methylenedioxy-methamphetamine is also known as ecstasy or molly; a hallucinogen A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? A. "I will report black stools to my doctor." B. "I will mix the medication with water." C. "I can prevent constipation if I drink more milk while taking this medication." D. "I can prevent nausea if I take the medication on an empty stomach." B. "I will mix the medication with water." A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? A. Client report of burning with urination B. Client report of uterine cramping C. Boggy fundus 3 fingerbreadths above the umbilicus D. Saturation of perineal pad in 15 min C. Boggy fundus 3 fingerbreadths above the umbilicus oxytocin (Pitocin) is used to stimulate uterine contractions and stop excessive bleeding. A boggy uterus indicates bleeding so that's why you want to massage the uterus to ensure that it's always firm. A nurse is attending an educational workshop about client confidentiality. Which of the following actions by the nurse indicates an understanding of the teaching? A. Changes her personal login password at random intervals B. Gathers data from clients on other units who have the same diagnosis C. Uses a personal digital assistant to record client information D. Disables the use of the speed-dial function on fax machines A. Changes her personal login password at random intervals A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend a home health referral? A. A young adult client who has a substance abuse disorder B. An older adult client who has heart failure and lives alone C. A middle adult client who had a mastectomy and requires chemotherapy D. An adolescent client who has a tibia fracture and requires crutches B. An older adult client who has heart failure and lives alone A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? A. You can safely take this medication if you become pregnant. B. You can skip a dose of this medication if you are nauseated. C. You might experience swollen gums while taking this medication. D. You should expect to have blood work every 6 months while taking this medication. C. You might experience swollen gums while taking this medication. phenyotin (Dilantin) is a hydantoin used for seizure disorders that causes gingival hyperplasia as an adverse effect A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/5 mL. How many mL should the nurse administer? (Round answer to the nearest tenth.) 7.5 mL A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching? A. I am having this test to check if my baby's lungs are mature. B. I am having this test because my baby was not reactive during a nonstress test. C. The nurse will draw my blood after the procedure to test(?). D. I will need to fast for 6 hours prior to the procedure. B. I am having this test because my baby was not reactive during a nonstress test. A nurse is discussing health practices with the mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping? A. I apply petroleum jelly with garlic along my child's wrist to treat infections. B. I insert needles into meridian lines of my child's body to help with pain relief. C. I rub the edge of a coin lengthwise on my child's back when he is sick. D. I sometimes place a bottle containing steam against my child's skin. D. I sometimes place a bottle containing steam against my child's skin. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? A. I should take a zinc supplement while taking this medication. B. This medication will dilate my eyes. C. I should check my heart rate while taking this medication. D. This medication will darken the color of my eyes. C. I should check my heart rate while taking this medication. timolol is a beta-adrenergic blocker used for primary open-angle glaucoma to reduce the production of aqueous humor. Beta-adrenergic blockers are also used for hypertension and cause bradycardia as an adverse effect. A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect? A. Jugular vein distention B. Moist mucous membranes C. Weight loss of 10% D. Capillary refill of 2 seconds C. Weight loss of 10% A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medications? A. Decreased liver function B. Decreased kidney function C. Increased metabolism D. Decreased pulmonary function B. Decreased kidney function A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral? A. Social worker B. Advanced practice nurse C. Patient care technician D. Psychologist B. Advanced practice nurse A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergic reaction to this medication? A. Arthralgia B. Fever C. Dyspnea D. Nausea C. Dyspnea A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician? A. A client who has a body mass index of 32 B. A client who has a sodium intake of 1200 mg/day C. A client who has a total fat intake of 25% of daily calories D. A client who has a serum albumin level of 4.5 g/dL A. A client who has a body mass index of 32 Normal serum albumin level is 3.5-5.5 g/dL. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. Soiled dressings should be placed in a biohazard trash receptacle B. Droplet precautions require that I wear a gown and gloves when providing care C. Following a blood spill, I should use a bleach solution with a ratio of 1 to 20 D. For a client who has Clostridium difficile, I will clean my hands with an alcohol-based rub A. Soiled dressings should be placed in a biohazard trash receptacle A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make? A. This medication will decrease the risk of hemorrhage in your newborn. B. This medication will increase the immunity of your newborn. C. This medication will increase the absorption of nutrients in the intestines. D. This medication will decrease the possibility of your newborn developing jaundice. A. This medication will decrease the risk of hemorrhage in your newborn. Vitamin K is also used as an antidote for warfarin (Coumadin), an antiplatelet medication which increases the risk of bleeding A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A. Fruity breath odor B. Elevated blood pressure C. Clammy skin D. Bounding pulse A. Fruity breath odor A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take? A. Cover the wound with a transparent film extending outward 5 cm (2 in) B. Replace the wound's dressing every 12 hr C. Use an adhesive remover to remove tape before reapplying a dressing D. Pack the wound tightly with sterile gauze C. Use an adhesive remover to remove tape before reapplying a dressing A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent? A. I should expect my periods to resume in 1 month. B. I am thankful I am done having children. C. I will have a large scar on my stomach after this procedure. D. I will no longer need a regular gynecological examination. B. I am thankful I am done having children. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A. Measure the duration of the seizure B. Restrain the client's arms and legs to prevent injury C. Lower the side rails of the bed when the seizure begins D. Insert an oral airway into the client's mouth A. Measure the duration of the seizure A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, "We've been trying to get pregnant for several months, but now I'm not so sure I'm ready." Which of the following responses should the nurse make? A. I wouldn't worry about it if I were you. You'll be a good mother. B. You need to talk to a therapist about how you're feeling. C. Why do you feel that way if you've been trying to get pregnant? D. Many women experience feelings of ambivalence during pregnancy. D. Many women experience feelings of ambivalence during pregnancy. A nurse is caring for four clients. Which of the following situations require a signed consent form? A. Performing a wound irrigation with an antibiotic solution B. Giving a haemophilus influenaze B vaccine to an infant C. Administering an iron injection Z-track method D. Inserting a nasogastric tube D. Inserting a nasogastric tube A nurse is receiving report on four clients. The nurse should plan to collect data from which of the following clients first? A. A preschooler who has epiglottitis and is drooling B. An adolescent who is postoperative and requesting pain medication C. An infant who is dehydrated and has a heart rate of 160/min D. A school-age child who has a broken ankle and report pruritus under his cast A. A preschooler who has epiglottitis and is drooling A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include? A. The headaches should decrease as you get used to the medication. B. Swallow the tablet whole to minimize your headaches. C. You should take the medication on an empty stomach to prevent a headache. D. You can't discontinue the medication until the headache goes away. A. The headaches should decrease as you get used to the medication. isosorbide dinitrate (ISDN) is a nitrate (such as nitroglycerin) used to treat angina pectoris. A common adverse effect of nitrates are headaches. A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take? A. Offer toileting every 6 hr B. Encourage intake of caffeinated beverages C. Limit fluid intake to 1500 mL a day D. Check for residual urine after voiding D. Check for residual urine after voiding A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care? A. Use a transcutaneous electrical nerve stimulator (TENS) B. Soak in a bathtub of hot water each night C. Obtain a prescription for pramipexole D. Lie on your left side with your top leg forward D. Lie on your left side with your top leg forward pramipexole is used to treat symptoms of Parkinson's disease and also restless legs syndrome (RLS) A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline (Elavil). Which of the following findings should the nurse include in the teaching as an adverse effect of this medication? A. Increased salivation B. Orthostatic hypotension C. Alopecia D. Polyuria B. Orthostatic hypotension amitriptyline (Elavil) is a tricyclic antidepressant (TCA). A common adverse effect is orthostatic hypotension and other serious effects such as dysrhythmias, which are usually fatal and the reason why TCAs are not the drug of choice for depression A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care? A. Suggest the client exercise before going to bed B. Recommend the client spend time alone in his room C. Encourage the client to use positive self talk D. Offer the client low-protein snacks throughout the day C. Encourage the client to use positive self talk A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many mL should the nurse administer? 1.5 mL A nurse is caring for a child who has terminated cancer. Which of the following responses by the child's school-age brother should the nurse expect? A. Believes that his brother's death will be reversible B. Alternates himself from his peers C. Believes his bad behavior is causing his brother's death D. Regresses to an earlier developmental level C. Believes his bad behavior is causing his brother's death A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse anticipate administering to prevent complications of withdrawal? A. Lorazepam B. Methimazole C. Potassium D. Naloxone A. Lorazepam lorazepam (Ativan) is a benzodiazepine used to treat anxiety and anxiety associated with alcohol withdrawal A nurse is reinforcing dietary teaching with a client whose pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy? A. 32 lb B. 24 lb C. 8 lb D. 16 lb D. 16 lb A nurse is assisting with the care of a client following electroconvulsive therapy (ECT) for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure? A. Paresthesias B. Tonic-clonic seizures C. Disorientation D. Sleep apnea C. Disorientation A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first? A. Instruct the client about effective coping strategies B. Suggest that the client assist with meal planning C. Observe the client during and after meals D. Refer the client to a support group for adolescents who have eating disorders C. Observe the client during and after meals A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations? A. Inform the client when beginning to observe the respirations B. Count the client's respirations for 15 seconds C. Place the client in a supine position D. Observe the movements of the client's chest wall D. Observe the movements of the client's chest wall A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report? A. Steps required for dressing change B. Admission vital signs C. Preferred bath time D. Time of last pain medication D. Time of last pain medication A nurse is reinforcing discharge teaching with a client who has a bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching? A. I will plan to increase my intake of green, leafy vegetables. B. I should follow a gluten-free diet while taking this medication. C. I should take this medication on an empty stomach. D. I will plan to avoid grapefruit juice while taking this medication. D. I will plan to avoid grapefruit juice while taking this medication. carbamazepine (Tegretol) is an anticonvulsant used for general anxiety disorder (GAD), trigeminal neuralgia and other manic-depressive disorders. Serious adverse effects include blood dyscrasias, Stevens-Johnson Syndrome, dyspnea, edema and hypertension. It should NOT be taken with grapefruit juice. An assistive personnel (AP) tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict? A. Grant the AP's request to reassign the task B. Ask the AP to discuss the issue in a private area C. Perform the tasks personally rather than reassigning them D. Reprimand the AP for failure to perform the tasks B. Ask the AP to discuss the issue in a private area A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching? A. Engage in low-impact aerobic exercises B. Apply ice to the inflamed joint C. Sleep on a soft mattress D. Use fingers to push off from the bed or chair A. Engage in low-impact aerobic exercises A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? A. Collect a sterile specimen from the urinary drainage bag B. Secure the tubing with adhesive tape to the lower abdomen C. Instruct the client too hold the drainage bag at waist height when ambulating D. Coil the tubing on the bed above the collection bag B. Secure the tubing with adhesive tape to the lower abdomen A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence? A. I am going to get a job to make some extra money. B. I plan to visit my friends while my husband is at work. C. I have decided to tell my husband I am leaving him. D. I just got accepted to our local college. C. I have decided to tell my husband I am leaving him. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect? A. Tachypnea B. Tachycardia C. Hypotension D. Hyperthermia C. Hypotension Magnesium sulfate is a tocolytic used for preterm labor (delays labor) by inhibiting contractions. It is also a CNS depressant used to prevent seizure in preeclampsia. A charge nurse working in a long-term care facility overhears two APs in the nurse's station discussing a client who was just admitted. Which of the following actions should the charge nurse take? A. Inform the client of the AP's actions B. Tell the APs to stop the conversation C. Document the event in the client's progress notes D. Submit an incident report to the risk manager B. Tell the APs to stop the conversation A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements made by the client indicates an understanding of the teaching? A. I do not need to sign a consent form before this procedure. B. I will feel a warming sensation after the injection of the dye. C. I can have a meal up to 2 hours before the procedure. D. I should limit my fluid intake for 2 days after the procedure. B. I will feel a warming sensation after the injection of the dye. A nurse is assisting with the plan of care for a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. Which of the following actions should the nurse take? A. Initiate a referral to a speech therapist B. Request a prescription for a glutamate antagonist C. Verify the status of the client's advance directive D. Suggest a genetic counseling for the client's family C. Verify the status of the client's advance directive A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching? A. I can take my baby to the lobby to visit family. B. I will carry my baby to the nursery. C. I can remove my security band to give it to a family member. D. I will have an identification band that matches the one my baby wears. D. I will have an identification band that matches the one my baby wears. A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions? A. Providing the client with information on community resources that will strengthen her coping skills B. Identifying the client's perception of the changes in her physical appearance C. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds D. Encouraging the client to write about her feelings in a journal each day B. Identifying the client's perception of the changes in her physical appearance A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse include in the teaching? A. Increase dietary intake of canned vegetables B. Limit caloric intake to 2500 calories per day C. Restrict alcohol intake to 360 mL (12 oz) of wine per day D. Walk for 30 min 5 days per week D. Walk for 30 min 5 days per week A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect? A. Reclusive B. Perfectionist C. Submissive D. Impulsive C. Submissive A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? A. Assign the client to a positive-airflow room B. Have visitors remain at least 0.91 m (3 feet) away from the client C. Administer aspirin if the client develops a fever D. Initiate contact precautions for the client D. Initiate contact precautions for the client A nurse is planning to administer four different medications to a client via gastrostomy tube. Which of the following actions should the nurse take? A. Let timed-release medications dissolve for 30 min prior to administration B. Mix crushed medications in 20 mL of water C. Flush with 10 mL of tap water after administration D. Allow separate medications to flow through the tube by gravity D. Allow separate medications to flow through the tube by gravity A nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. Which of the following supplies should the nurse use while caring for this client? A. Surgical mask B. Gown C. Sterile gloves D. N95 respirator A. Surgical mask A nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. Which of the following statements by the client indicates an understanding of the teaching? A. I drink whole milk everyday. B. I may have four egg yolks per week. C. I make toast using enriched white bread. D. I have unsalted pretzels for a snack. D. I have unsalted pretzels for a snack. A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian culture. Which of the following communication techniques by the nurse demonstrates cultural sensitivity? A. Sitting closer than an arm's length B. Patting the client's shoulder for reassurance C. Using social conversation to fill periods of silence D. Holding eye contact for brief instances D. Holding eye contact for brief instances A nurse is reinforcing teaching about safe food handling with a client who is recovering from food poisoning. Which of the following statements by the client indicates an understanding of the teaching? A. I will set my refrigerator to 50 degrees Fahrenheit. B. I will be sure to cook chicken to 180 degrees Fahrenheit. C. It is safe to eat unpasteurized dairy products. D. It is safe to use uncooked ground beef that has been refrigerated for 4 days. B. I will be sure to cook chicken to 180 degrees Fahrenheit. A nurse is assisting with the discharge plan for a client who has burns on his arms and hands. Which of the following referrals should the nurse recommend to improve the client's ADLs? A. Social worker B. Occupational therapist C. Case manager D. Registered dietician B. Occupational therapist A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following? A. Chadwick's sign B. Hegar's sign C. Chloasma D. Ballottement A. Chadwick's sign Hegar's sign is indicated by a softening of the uterus. Chloasma is when brown patches appear on the face and is also known as the "mask of pregnancy." Ballottement is a confirmation of pregnancy when the provider feels the rebound of the fetus following a quick digital tap on the wall of the uterus. A nurse should recognize that a client's right to confidentiality has been breached when which of the following occur? A. A nurse tells the chaplain that her assigned client has a new diagnosis of cancer B. A social worker reads a client's chart as a follow-up to a requested consultation C. A facility risk manager includes information from a client's medical record in a written report D. A newly licensed nurse discusses his client's postoperative complications during shift report A. A nurse tells the chaplain that her assigned client has a new diagnosis of cancer A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions? A. A client who had a lobectomy and has a chest tube drainage system B. A client who had a radical mastectomy 36 hr ago and has a surgical drain C. A client who has cervical cancer and an internal radioactive implant D. A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy B. A client who had a radical mastectomy 36 hr ago and has a surgical drain A nurse is reviewing laboratory values for a client who has respiratory acidosis. Which of the following arterial blood gas values should the nurse expect? A. pH 7.45 and PaCO2 35 mm Hg B. pH 7.35 and PaCO2 52 mm Hg C. pH 7.28 and PaCO2 28 mm Hg D. pH 7.30 and PaCO2 50 mm Hg D. pH 7.30 and PaCO2 50 mm Hg pH 7.30 is below the normal range of 7.35-7.45 so it's acidic. PaCO2 of 50 mm Hg is above the normal range of 35-45 mm Hg so it's respiratory. ROME so respiratory is opposite (pH goes down and PaCO2 goes up) A nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room. Identify the sequence of actions the nurse should take. (Move steps in order). A. Pull the nearest fire alarm B. Attempt to extinguish the fire C. Move the client to a safe location D. Shut all doors and windows C. Move the client to a safe location A. Pull the nearest fire alarm D. Shut all doors and windows B. Attempt to extinguish the fire A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicate that the client is experiencing an adverse effect of the medication? A. Lacrimation B. Hypertension C. Urinary retention D. Tachycardia C. Urinary retention morphine is an opiate agonist (like codeine, hydrocodone, oxycodone, meperidine [Demerol], tramadol) used for acute or chronic moderate/severe pain. Common adverse effects include constipation, orthostatic hypotension and sedation. Serious adverse effects include respiratory depression and urinary retention. A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the teaching? A. Peanut butter B. Dark chocolate C. Cream of potato soup D. Skim milk D. Skim milk Clients with cholecystitis should have diets low in fat. A nurse is caring for a client who has a new mastectomy. Which of the following statements by the client should indicate to the nurse that the client is beginning to cope with the changes in her body image? A. I am afraid to discuss my concerns with my husband. B. I am angry I had to lose my breast. C. I am worried I will never be able to take care of myself. D. I am not ready to change my own dressing. A. I am afraid to discuss my concerns with my husband. A nurse is caring for for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make? A. Establish a daily exercise routine B. Keep the telephone volume low while you are trying to fall asleep C. Remain in bed until you fall asleep D. Sleep longer hours on the weekend A. Establish a daily exercise routine A nurse is caring for an adolescent that states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms? A. Denial B. Regresson C. Repression D. Sublimaton D. Sublimation Sublimation is directing unacceptable behaviors into a socially acceptable area. Example: A student who is angry with a faculty member writes a short story of a hero. A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of this medication? I will place the patch on a hairless area of skin. A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching? Encourage the client to be assertive A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include in the meal tray? Roasted salmon A nurse is preparing to administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the following times should the nurse plan to check the client for hypoglycemia? 1100 NPH insulin is an intermediate-acting insulin that peaks in 4-14 hours A nurse in a clinic is obtaining a health history from a client scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the most important for the nurse to ask? "Do you know if you're allergic to iodine?" The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies. A nurse in an urgent care facility is collecting data from a client who is scheduled for a procedure. Which of the following clinical manifestations indicates a possible latex allergy? Rhinorrhea A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client demonstrates understanding of the teaching? "I will rinse my mouth after taking this medication." A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep vein thrombosis. Which of the following actions indicates that the AP is applying the stockings correctly? The AP applies the stockings before getting the client out of bed A nurse working in a provider's office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the following responses by the nurse is correct? "When all the blisters have scabbed over." A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the following values should the nurse expect if the client is in respiratory acidosis? PaCO2 51 mm Hg A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse reinforce to the client? Apply the prosthesis immediately upon waking each day A nurse is preparing a client for the insertion of an NG tube. Which of the following actions should the nurse take? Determine if the client has a deviated septum A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the following findings should the nurse report to the provider? Client report of decreased sensation in the finger A nurse is contributing to the plan of care for a client who is on suicide precautions. Which of the following interventions is appropriate for the nurse to recommend? Encourage the client to sign a no-harm contract A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostic tests should the nurse expect to be prescribed? Cerebrospinal fluid (CSF) analysis A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make? If you'd like to wear a wig, you should select it before hair loss occurs. A charge nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first? Confront the AP about the suspected impairment A nurse is caring for a client who has asthma and has a prescription for theophylline 200 mg PO BID. Which of the following should the nurse include in the teaching? Discontinue drinking caffeinated beverages theophylline is a xanthine derivative used to treat asthma While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct understanding by the nurse about ergonomic principles? Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client's medications prior to contacting the provider. Which of the following medications is the likely cause of the increased sedation? lorazepam (Ativan) lorazepam (Ativan) is a benzodiazepine that is used for generalized anxiety disorder (GAD) and for anxiety associated with alcohol withdrawal. Common adverse effects include sedation, drowsiness and lethargy. A nurse is caring for a client who had a bronchoscopy and just arrived to the medical-surgical unit. Which of the following actions should the nurse perform first? Check for a gag reflex A client is requesting information from a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate? The person you appoint will make health care decisions for you if you cannot do so yourself. A nurse enters a client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse do first? Assist the client to a nearby waiting area A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statements made by a client indicates that he may have a premalignant lesion? I have this flat, scaly area with red edges on my neck. A nurse is caring for a client who reports 12 liquid stools in the past 8 hours. Which of the following findings indicates that the client is experiencing dehydration? Potassium level 2.5 mg/dL Normal range for serum potassium is 3.5-5 mg/dL A nurse is providing anticipatory guidance to the parent of a 6 year old child. Which of the following statements by the parent indicates an understanding of appropriate safety precautions for the child? "I will encourage my child to wear a bicycle helmet whenever bike riding." A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicates that the client is experiencing a fluid volume deficit? Orthostatic hypotension A nurse is caring for a client who is receiving warfarin (Coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8. Which of the following actions should the nurse take? Withhold the ordered dose of the medication Normal INR is 0.8-1.1. If a client requires anticoagulation, the desired value is increased to approximately 2-3. A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching? The infant is lying in the crib with a stuffed animal A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B? Performing oral hygiene A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following? From onset of symptoms until 24 hours of antibiotic therapy A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that he "felt something pop" when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first? Cover the wound with sterile saline-soaked gauze A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan? Increase counter traction every 24 hours OR Inspect the ropes, knots and pulleys every 8 hours A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take? Use a designated stethoscope for the toddler A client's daughter calls the nurse requesting information about her mother's condition. The client's chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse? "You will need to contact your mother directly about her condition." A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam. Which of the following should indicate to the nurse that the child is not current with the minimum required immunizations? One MMR vaccine Children should receive 2 doses of the MMR vaccine by the time they're 9 years old: one at 12-15 months and another at 4-6 years old A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she: Develops edema of the ankles A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate? Monitor the client's skin integrity on a regular schedule A nurse working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate? Aggressive behavior A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first? A client who has COPD and dementia and was agitated during the night shift A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use? Leave space between the tip of the penis and the end of the condom catheter A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take? Ask the client to flex the hips and knees A nurse is supervising an assistive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take? Reinforce safe meal setup techniques A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client's understanding of the teaching when the client states: "I will install gates at the top and bottom of the stairs." A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states: "I guess I have to take some of the blame because of the way my friends and I dress." Suppression is deliberately trying to forget or not think about painful or unwanted thoughts. A client is prescribed 2 g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client? 4 tablets A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following statements by the client indicates a need for further teaching? "I will walk barefoot to prevent slipping." A client with emphysema asks the nurse why he has difficulty breathing. Which of the following statements by the nurse is appropriate? "Your windpipe is inflamed and constricted." A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client? Irritability A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparation classes. Which of the following responses by the nurses supports the partner's involvement during labor? "Breathing with your partner will help her to relax during contractions." A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first? Remove the tracheostomy inner cannula A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching? (Select all that apply.) Wash the bed linens in hot water Clean the child's toys with a 1:10 bleach solution Pediculosis capitis is head lice infestation A nurse caring for the mother of a newborn finds the client crying in her room. The client tells the nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate? Encourage the client to share her feelings A nurse is assisting with the care of a 36 year old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identify: Chromosomal abnormalities A nurse is caring for a client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching? nicotinic acid (Niacin) nicotinic acid (Niacin), also known as vitamin B3, is used for dyslipidemias to lower cholesterol A nurse is caring for a client who is 12 hours postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first? Massage the fundus OR Obtain the client's vital signs A nurse working at an inpatient mental health facility is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? Record the amount of food the client consumes A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following statements indicates an understanding of the teaching? I will dispose of my needles in a plastic laundry detergent container A nurse is visiting the home of a client who recently had a total hip arthroplasty. During observation of the client's home, which of the following findings places the client at risk for falls? (Select all that apply.) Medication stored on the top shelf of the cupboard Client walks barefoot in the house A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin (Nitrostat) sublingual tablets for treatment of angina. Which of the following instructions should the nurse include? Take up to 3 tablets during a single angina episode A nurse is caring for a client who has right-sided heart failure. The client's partner expresses concern that the client will die. Which of the following is an appropriate response by the nurse? "It is difficult to see someone so sick. What have you been told about your partner's prognosis?" A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa (Epogen). Which of the following instructions should the nurse include? Administer the medication subcutaneously A nurse is caring for a client who has a Salem Sump tube connected to intermittent wall suction. Which of the following nursing interventions should the nurse perform? Reposition the client every 2 hours Salem Sump tubes are used for NG A nurse in a provider's office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (Select all that apply.) Store the child's clothing in a separate cubicle when at school Boil brushes and combs in water for 10 minutes Dry bed linens and clothing in a hot dryer for at least 20 minutes A nurse is contributing to the plan of care for an adolescent who has cystic fibrosis. Which of the following diets should the nurse recommend? High-calorie A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the medical record to locate information about the client's personal health insurance? Admission sheet A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include? "You will need to schedule a bone density test." prednisone is a glucocorticoid ("steroid") used for inflammatory disorders and also for adrenal hormone replacement (for Addison's disease.) An adverse effect of glucocorticoids is osteoporosis. A nurse is assisting in the admission of a client who has diabetic ketoacidosis to a medical unit. Which of the following IV solutions should the nurse anticipate administering first upon admission? 0.9% sodium chloride 0.9% sodium chloride (normal saline) is an isotonic solution used for fluid replacement as in the case of diabetic ketoacidosis (when a diabetic person becomes dehydrated) A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings is the priority? Tingling around the mouth Tingling around the mouth can be a possible indication of hypocalcemia A nurse is collecting data from an older adult client who is receiving a unit of packed RBCs. Which of the following findings should the nurse report to the provider as an indication of circulatory overload? Crackles heard on auscultation A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better." Which of the following responses by the nurse is appropriate? "You're saying that you are doubtful that this procedure will benefit you." A nurse is preparing to provide suctioning for a toddler who has a tracheostomy. Which of the following actions should be included in the plan of care? Allow the child to rest for 45 seconds between aspirations A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suction. Which of the following supplies does the nurse need to perform this task? Yankauer catheter Yankauer catheters are commonly used for suctioning A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions by the nurse is appropriate? Wear a surgical mask within 3 feet of the client A nurse is collecting data from a client who has cholecystitis. In which of the following locations should the nurse expect the client to report pain? Right upper quadrant The parents of a 12-month-old voice their concern that their child is crawling but not pulling herself up to stand like the other children at the day care center. The nurse should recommend to the parents that they should: Have the child evaluated by a pediatrician A nurse recognizes that nurse-client communication is effective when the client: Asks the nurse to listen to potential solutions A nurse is caring for a client who is receiving IV fluids. As the nurse enters the room, the IV pump's alarm begins beeping. The client tells the nurse, "That happens all the time. Just turn off the alarm." Which of the following actions should the nurse take first? Observe the IV site A nurse is caring for a client who is scheduled for colonoscopy with polyp removal. Which of the following client statements should alert the nurse that the client may be at risk for complications from the procedure? "I needed three ibuprofens for my arthritis pain last night." ibuprofen (Advil) is a NSAID that causes GI irritation and GI ulcers that may bleed A nurse is reinforcing teaching with the parents of a newborn about physical assessments. Which of the following statements by the parent demonstrates understanding of the newborn hearing screening test? "If my baby fails the hearing test, he will need to be tested in 3 months." A nurse is reviewing instructions with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.) Expose the glans of the penis Cleanse the penis using an antiseptic swab Begin urination Pass the cup into the urine stream Move the cup out of the urine stream Replace the foreskin A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following actions should the nurse take? Provide step-by-step instructions for performing ADLs A nurse is reinforcing teaching about breastfeeding with a pregnant client. Which of the following statements by the nurse is appropriate? "Breastfeeding reduces the infant's risk of infection." A nurse is reviewing client positioning for a thoracentesis with a newly licensed nurse. The nurse validates the newly licensed nurse's understanding when he indicates that the client should be placed in which of the following positions for the procedure? Leaning forward over pillows A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by a parent indicates an understanding of the teaching? "I can place a rolled towel on each side of my newborn's head until he can hold his head up." A nurse is preparing to apply a pulse oximeter to a client's finger. Which of the following actions should the nurse take before applying the sensor? Check the client's capillary refill A nurse is caring for a client who is asking about the technique of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique? "It is a light stroking of the skin during a uterine contraction." A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoperative pain. Which of the following is an adverse effect of this medication? Urinary retention hydromorphone (Dilaudid) is an opioid analgesic used to treat acute to chronic moderate/severe pain. Adverse effects include constipation, urinary retention and respiratory depression. A nurse is administering medications. A client states, "I know that the Inderal helps my blood pressure, but I don't like the way it makes me feel. I don't think I'll take it today." Which of the following actions should the nurse take? Ask the client to describe what he is experiencing A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate? "Think about a pleasant memory as you visualize your pain floating away." A nurse is caring for an older adult client who is postoperative following a total hip replacement. The client is incontinent of stool and urine. To prevent skin breakdown, the nurse should: Apply moisture-absorbing undergarments A client comes to the clinic with reports of nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe? pseudoephedrine (Sudafed) pseudoephedrine (Sudafed) is a sympathomimetic decongestant used to relieve congestion A nurse in a provider's office is reinforcing teaching to the parents of a school-age child who has an ankle sprain. The nurse should include which of the following statements in the teaching? Offer aspirin every 4 hours for discomfort OR Elevate the affected extremity to a level higher than the heart A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for further data collection? Inappropriate words when speaking A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention? States he is being told to hit his roommate A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first? Check for proper fit of the mask on the CPAP machine OR Provide activities during the day to stimulate the client A nurse is caring for a client in the provider's office who is experiencing an episode of acute asthma. The nurse should administer which of the following medications? triamcinolone (Azmacort) triamcinolone (Azmacort) is a glucocorticoid used as an anti-inflammatory for mild, moderate and severe persistent asthma. It is also antiallergenic and immunosupressant. A nurse is assisting with the care of a client who is receiving IV therapy of 0.9% sodium chloride. The client received 200 mL more than prescribed in 1 hour because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because: The client was not harmed as a result of the incident. A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching? "I will rinse my mouth with room-temperature saline solution." A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hours postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage? Frequent swallowing A nurse is caring for an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect? Absence of menses A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylactic reaction? Wheezing A nurse is admitting a client with active tuberculosis (TB). Which of the following is an appropriate nursing intervention? Place the client in a room that is ventilated to the outside A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report? A client had a blood glucose of 140 mg/dL A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regular insulin (Humulin R) 15 units SQ. Which of the following actions should the nurse perform first? Inject 10 units of air into the NPH insulin vial Regular insulin gets drawn FIRST then NPH insulin gets drawn after A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a wound vacuum to be applied. Which of the following is an appropriate nursing action? Maintain hydrophilic material deep into the ulcer A nurse is reinforcing teaching to a client who has been taking digoxin 0.25 mg PO daily for 6 months. Which of the following indicates a need for further teaching? I will call my provider if I experience a yellow tinge to my vision. A nurse receives a verbal order for a client to receive a stat dose of meperidine (Demerol) 100 mg PO. She administers the medication, charts the administration, and then realizes she has administered phenytoin (Dilantin) 100 mg PO. After obtaining the client's vital signs, which of the following actions should the nurse take? Notify the provider meperidine (Demerol) is an opiate agonist and phenytoin (Dilantin) is a hydantoin used for seizures A nurse is administering medications to a client. Which of the following actions is appropriate for the nurse to take? Verify with another nurse when calculating a new dose of medication A nurse is reinforcing discharge teaching to a client who is prescribed propylthiouracil. For which of the following should the nurse instruct the client to monitor and report to the provider immediately? Sore throat propylthiouracil (PTU, Propacil) is an anti-thyroid agent used for hyperthyroidism. Clients should report sore throat because it's an indication of infection, a side effect of bone marrow suppression and leukocyte deficiency. Clients should also report hypothyroidism, nephrotoxicity and hepatotoxicity. A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following client statements indicate to the nurse a need for further teaching? "I will soak my feet in warm water every night." A nurse is caring for a client who has heart failure and is taking furosemide (Lasix). Which of the following statements made by the client indicates a need for the nurse to intervene? "I have to sleep sitting up." A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching? "I will leave the patch on for 12 to 14 hours each day." A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error? Incident report A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement? Take the client for a walk to the recreation room A nurse is caring for a client who is in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Place the bed in the lowest position A nurse is preparing to irrigate a wound of a client who has methicillin-resistant Staphylococcus aureus (MRSA). The nurse should use which of the following personal protective equipment? A face shield A nurse is collecting data for a client who has been receiving medroxyprogesterone acetate (Depo-Provera) for the past 6 months. Which of the following statements made by the client should be reported to the provider? "I'm experiencing calf pain." medroxyprogesterone acetate (Depo-Provera) is a form of hormonal birth control. A nurse is reinforcing teaching with a new mother regarding the use of breast milk. Which of the following statements by the mother indicates an understanding of the teaching? "I can store my breast milk in the freezer for up to 6 months." A nurse in a long-term care facility is caring for a client who has a spinal cord injury. The client is demonstrating manifestations of autonomic dysreflexia. Which of the following actions should the nurse take first? Loosen the client's clothing OR Check the client for bladder distention A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates the medication is effective? A. "Our child has lost some weight since his last appointment." B. "Our child is able to complete his homework on time." C. "Our child has an increased daily caloric intake." D. "Our child has a better grasp of reality." B. "Our child is able to complete his homework on time." methylphenidate (Ritalin) is a CNS stimulant used for the treatment of ADHD, ADD and narcolepsy. A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication? A. Hyperglycemia B. Hypertension C. Hematuria D. Tinnitus B. Hypertension tranylcypromine (Parnate) is a monoamine oxidase inhibitor (MAOI) used for treatment of depression. Clients taking MAOIs need to avoid foods high in tyramine to avoid life-threatening hypertensive crisis. Clients should also avoid sympathomimetic drugs (OTC cold and cough drugs), TCAs (amitriptyline) and SSRIs (fluoxetine, citalopram, sertraline) and SNRIs (venlafaxine, duloxetine). A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following should the newly licensed nurse identify as an accurate transcription? A. Dozazosin 5 mg PO at bedtime B. Heparin 5000 U subq every 8 hr C. Lorazepam 0.5 mg PO PRN at bedtime D. MgSO4 10 g PO daily D. MgSO4 10 g PO daily A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological therapy to manage pain when changing positions. Which of the following responses should the nurse make? A. "You can apply counterpressure to your back with each position change." B. "You can splint the incision with a pillow when changing positions." C. "You should use patterned-paced breathing when changing positions." D. "You should change positions as little as possible." B. "You can splint the incision with a pillow when changing positions." A nurse is collecting data from a client who has left-sided heart failure. For which of the following findings should the nurse notify the provider? A. Pale, clammy skin B. Fatigue when ambulating 152 m (500 ft) C. Productive cough with pink, frothy sputum D. Weight loss of 1 kg in the past 25 hr C. Productive cough with pink, frothy sputum A nurse is collecting a health history from the guardian of a 4 year old child. Which of the following should the nurse address? A. "I have a difficult time getting my child to eat green vegetables." B. "My child continually asks me the same questions." C. "I have noticed that my child is withdrawn since we switched day care providers." D. "My child still wets the bed at least two times per week." C. "I have noticed that my child is withdrawn since we switched day care providers." A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take? A. Tell the client to push during contractions B. Instruct the client to change positions frequently C. Encourage the client to soak in a hot bath D. Apply fundal pressure during contractions B. Instruct the client to change positions frequently A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide? A. Wash the tips of your crutches daily B. Keep your elbows flexed at a 35 degree angle when using the crutches C. Maintain your head and neck erect when walking with crutches D. Support your body weight by leaning on the crutches C. Maintain your head and neck erect when walking with crutches A nurse is collecting data from a 10 month old infant during a well visit. Which of the following findings should the nurse identify as a manifestation of torticollis? A. Asymmetry in gluteal folds B. Feet turn inward C. Frenulum connected to the tip of the tongue D. Neck in a flexed position D. Neck in a flexed position A nurse is caring for a client who has bipolar disorder. The client yells at one nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms? A. Conversion B. Splitting C. Sublimation D. Displacement D. Displacement Displacement is when a person redirects a negative emotion from its original source to a less threatening recipient. A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching? A. You can remove your eye patch during the day B. You can apply warm, moist compresses to your forehead to reduce pain C. You should bend from the waist to pick up an object D. You can take a stool softener to prevent constipation D. You can take a stool softener to prevent constipation A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5 degrees Celsius (90.5 degrees Fahrenheit.) Which of the following data is the priority for the nurse to monitor? A. Urinary output B. Pain sensation C. Heart rhythm D. Muscle strength C. Heart rhythm A nurse is giving a change-of-shift report on a group of clients. Which of the following statements should the nurse make? Select all that apply. A. "The client in room 205 has had several visitors today." B. "The client in room 205 is scheduled for a dressing change at 1800." C. "The client in room 204 has a new prescription for IV gentamicin." D. "The client in room 204 received some pain medication earlier today." E. "The client in room 203 will undergo surgery at 0900 tomorrow." C. "The client in room 204 has a new prescription for IV gentamicin." D. "The client in room 204 received some pain medication earlier today." E. "The client in room 203 will undergo surgery at 0900 tomorrow." A nurse is reinforcing dietary teaching with a client who is at 12 weeks of gestation. Which of the following statements should the nurse make? A. Increase your dietary intake by 500 calories per day B. Limit your caffeine intake to 700 mg per day C. Eat 40 mg of protein-rich foods per day D. Consume 600 mg of folic acid per day A. Increase your dietary intake by 500 calories per day A nurse is providing site care for a child who has a skin level device gastrostomy enteral tube. Which of the following actions should the nurse take? A. Apply water-soluble lubricant to the site B. Tape the tube to the child's cheek C. Apply a skin barrier protectant to the site D. Cleanse the site with warm soap and water C. Apply a skin barrier protectant to the site A nurse is caring for a 3 year old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take? A. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days B. Gently massage the eyelid to facilitate absorption of the medication C. Wipe any excess medication from the inner canthus outward D. Place an occlusive dressing on the affected eye to prevent the spread of infection C. Wipe any excess medication from the inner canthus outward A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regiment. Which of the following instructions should the nurse include? A. Exercise when insulin is at its peak action B. Avoid protein before exercising C. Inject additional insulin before exercising D. Eat a piece of fruit before exercising D. Eat a piece of fruit before exercising A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect? A. Increased appetite B. Loose stools C. Bladder infections D. Loss of taste B. Loose stools A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take? A. Remove the stockings once every 24 hours B. Have the client point his toes before inserting his foot into the stocking C. Roll the top of the stocking down so it fits snugly above the client's calf D. Elevate the client's legs for 5 mins prior to applying the stockings A. Remove the stockings once every 24 hours A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time? Select all that apply. A. Make a priority to-do list at the beginning of the shift B. Complete activities with one client before moving to another client C. Plan a time at the end of the shift to document nursing interventions D. Keep track of how long it takes to complete certain tasks E. Delegate collection of vital signs to the assistive personnel on the team A. Make a priority to-do list at the beginning of the shift B. Complete activities with one client before moving to another client E. Delegate collection of vital signs to the assistive personnel on the team A home health nurse is reinforcing teaching about home safety with an older adult client who lives alone. Which of the following client statements indicates an understanding of the teaching? A. I will have my hearing tested every 2 years B. I will make sure the electrical wires are run under carpeting C. I will have the heating system inspected once every 3 years D. I will make sure that hot water faucets are color-coded D. I will make sure that hot water faucets are color-coded A nurse is collecting data from a client who is postoperative following placement of a colostomy in the ascending colon. Where on the body would it be located? On the right side of the abdomen A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan? A. Limit fluid intake to 1000 mL daily B. Provide the client with three large meals each day C. Place the client in an orthopneic position D. Encourage the client to cough and deep breathe once every 8 hours C. Place the client in an orthopneic position A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse suspect the client has hypernatremia? A. Hypothermia B. Altered mental status C. Dysrhythmias D. Nausea and vomiting B. Altered mental status A nurse is reinforcing teaching with a client who has undergone a vein stripping of the right leg. Which of the following should the nurse include in the teaching? A. Maintain bed rest for 48 hours B. Wrap the left with an elastic bandage C. Implement a sodium-restricted diet D. Keep legs in a dependent position C. Implement a sodium-restricted diet A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure? A. The AP pulls the pinna up and back B. The AP points the probe posteriorly C. The AP positions the client facing her D. The AP inserts the probe with a straight, forward motion A. The AP pulls the pinna up and back A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make? A. Are you thinking of hurting yourself? B. What would your family do without you? C. Why would you think like that? D. When you get better, you will not feel this way. A. Are you thinking of hurting yourself? A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? Select all that apply. A. Obtain a baseline reading of the FHR and contraction pattern B. Position the client with a rolled towel under her hips C. Pass the sterile hook to the provider D. Check the fluid for color, odor and consistency E. Document the procedure in the electronic medical record All of them?? A. Obtain a baseline reading of the FHR and contraction pattern B. Position the client with a rolled towel under her hips C. Pass the sterile hook to the provider D. Check the fluid for color, odor and consistency E. Document the procedure in the electronic medical record A nurse is caring for a client who adheres to kosher dietary practices. Which of the following foods should the nurse plan to offer the client? A. Shrimp and french fries B. Bacon and eggs C. Cheeseburger D. Chicken sandwich D. Chicken sandwich A nurse is reinforcing teaching with the guardians of a 6 year old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching? A. Have your child wear a medical identification wristband B. Provide homeschooling for your child C. Ensure that your child does not receive the influenza vaccine annually D. Do not include your child when making decisions about treatment A. Have your child wear a medical identification wristband A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching? A. The client's extremity should be elevated after the cast is applied B. The client should keep the cast covered until it is dry C. The client can shower with the cast after 24 hours D. The client should use a hair dryer on a warm setting to relieve itching inside the cast A. The client's extremity should be elevated after the cast is applied A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse identify as a positive outcome of treatment? A. The client develops lanugo B. The client's pulse rate is 44/min C. The client's potassium level is 2.7 mEq/L D. The client resumes menstruation D. The client resumes menstruation A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching? A. "I should do aerobic exercises once per day." B. "I should practice pursed-lip breathing exercises." C. "I will consume low protein, low calorie foods." D. "I will increase my fluid intake to 1700 mL per day." B. "I should practice pursed-lip breathing exercises." A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make? A. Take the medication and then lay down for 30 mins B. Take the medication with calcium-fortified orange juice C. Take the medication with crackers D. Take the medication with an antacid C. Take the medication with crackers A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse? A. Blood pressure 110/70 mm Hg B. Respiratory rate 16/min C. Fluctuation in the water seal chamber with respiration D. 400 mL of drainage in the collection chamber within 4 hr D. 400 mL of drainage in the collection chamber within 4 hr A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use? A. Tie the gown with the gloves on B. Tuck the glove cuffs under the gown sleeves C. Apply the gown before the gloves D. Push the gown sleeves up to the elbow C. Apply the gown before the gloves A nurse is transcribing a client's prescription for erythromycin 500 mg 4 times per day. Which of the following information should the nurse clarify with the provider? A. Time B. Route C. Dosage D. Medication B. Route A nurse is providing preoperative care to a client who reports that he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? A. Contact the next of kin to assist the client at home B. Assist with a referral to a home health care agency C. Call the provider about admitting the client to the facility overnight D. Give the client a list of home care assistants to contact B. Assist with a referral to a home health care agency A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan to take? A. Give a dose of alendronate B. Monitor for Chvostek's sign C. Administer furosemide D. Apply a cardiac monitor D. Apply a cardiac monitor A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include? A. Leukorrhea B. Swelling of the face C. Burning during urination D. Diarrhea B. Swelling of the face A nurse is caring for a client who has schizophrenia. Which of the following behaviors of the client should the nurse identify as a negative symptom of schizophrenia? A. Smells odors that don't exist B. Has a preoccupation with religious thoughts C. Initiates speech rarely D. Mimics the nurse's movements C. Initiates speech rarely A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop treatment. Which of the following actions should the nurse take? A. Discuss alternative treatment methods with the client B. Tell the client she should discuss this decision with her family C. Ask the facility chaplain to visit the client D. Support the client's decision to stop the treatment D. Support the client's decision to stop the treatment A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifications should the nurse use to verify the identities of each client? A. The telephone number of the clients B. The diagnoses of the clients C. The room number of the clients D. The name of the client's nearest relatives A. The telephone number of the clients A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of the following actions should the nurse take to provide denture care? A. Store the dentures in a dry denture cup on the bedside table after cleaning B. Use a circular motion to cleanse the biting surface of the dentures C. Remove the lower dentures before the upper dentures D. Place a towel in the sink when cleaning the dentures B. Use a circular motion to cleanse the biting surface of the dentures A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make? A. You should only drink 2 cups of coffee per day B. You should eat three large meals and two snacks per day C. You should elevate the head of the bed while sleeping D. You should lay down for 1 hour following a meal C. You should elevate the head of the bed while sleeping A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include? A. Give the toddler a sticker after each successful toileting attempt B. Have the toddler remain on the toilet for a minimum of 20 minutes C. Wake the toddler every 2 hr in the night to prevent bed wetting D. Encourage the toddler to flush the toilet while still seated A. Give the toddler a sticker after each successful toileting attempt A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parents demonstrates understanding of the teaching? A. It is recommended that my child receive his first flu immunization at the age of 6 B. My child will need to start the human papillomavirus series when he enters kindergarten C. I can make several office visits, so my child does not get so many immunizations at once D. I understand that immunizations will be withheld if my child has lactose intolerance C. I can make several office visits, so my child does not get so many immunizations at once A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve client's sleep. Which of the following instructions should the nurse include? A. Open curtains between clients in semiprivate rooms B. Turn on overhead lights briefly when checking IV lines C. Conduct change-of-shift report near the client's room D. Wear shoes with rubber soles B. Turn on overhead lights briefly when checking IV lines A nurse in a family practice office routinely reviews client's immunization statuses at their annual physical examination visit. Which of the following clients should the nurse recommend a human papillomavirus immunization? A. A teenage boy B. A preschool age girl C. An older adult woman D. A middle-aged man A. A teenage boy A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include? A. Cause of the client's death B. Location of the identification tag on the client's body C. Last set of the client's vital signs D. Copy of the client's advance directives C. Last set of the client's vital signs (?) A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? A. Collecting a sputum culture B. Administering a subcutaneous insulin injection C. Providing discharge teaching about home IV medication therapy D. Removing a NG tube C. Providing discharge teaching about home IV medication therapy A nurse is reviewing the laboratory values of a client who has COPD. Which of the following findings should the nurse report to the provider? A. Iron 150 mcg/dL B. Potassium 3.7 mEq/L C. WBC 1300/mm3 D. Hgb 20 g/dL C. WBC 1300/mm3 Normal WBC is 4,500-11,000/mm3 A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect? A. Circulatory overload B. Acute hemolytic C. Anaphylactic D. Febrile C. Anaphylactic A charge nurse in a long-term care facility is discussing ethical theories with a group of newly licensed nurses. Which of the following should the charge nurse identify as an indication that a newly licensed nurse understands utilitarianism? A. "I will respect the decision of a client who has a chronic illness to stop treatment." B. "I will place a higher emphasis on human dignity than on the needs of a group." C. "I will withhold a terminal diagnosis from a client who has cancer." D. "I will consider what is going to benefit the most people when making decisions." D. "I will consider what is going to benefit the most people when making decisions." Utilitarianism focuses on what will benefit the majority of a group A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make? A. It includes restriction of nutritional support B. It is for clients who have a terminal illness C. It is for clients who are given 6 months or less to live D. It enhances quality of life by promoting comfort D. It enhances quality of life by promoting comfort A nurse is caring for a client who is 12 hours postpartum and has deep vein thrombosis of the left leg. The client is receiving an anticoagulant. Which of the following actions should the nurse take? A. Administer aspirin for pain B. Massage the affected extremity every 4 hr C. Apply an ice pack to the affected extremity for 20 mins every 2 hr D. Initiate bed rest C. Apply an ice pack to the affected extremity for 20 mins every 2 hr A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make? A. Discontinue this medication if this occurs again B. Restrict your daily fluid intake C. Sit back down for a few minutes when this occurs D. Take a daily potassium supplement C. Sit back down for a few minutes when this occurs A nurse is collecting data from a 9 year old during a well child visit. Which of the following findings should the nurse expect? A. Demonstrates self-centered thinking B. Expresses conflict over independence and control C. Displays emotional detachment from parents D. Grasps concept of cause and effect D. Grasps concept of cause and effect A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching? A. Give the client a straw to use for drinking B. Use a needleless syringe to instill feedings C. Provide thin liquids to help the client swallow D. Place oral suction equipment next to the client's bedside D. Place oral suction equipment next to the client's bedside A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include? A. Hold the hands slightly higher than the elbows when using running water B. Dry hands thoroughly from fingers to wrist C. Wash hands under running water for at least 10 seconds D. Clean hands with alcohol-based gel for 15 seconds B. Dry hands thoroughly from fingers to wrist A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following should the nurse expect at the insertion site? A. Pruritus B. Erythema C. Edema D. Blood C. Edema A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching? A. I will need to remain upright for 1 hour after taking the medication B. I have to take this medication on an empty stomach C. I can take antacids at the same time as this medication D. I should expect to have diarrhea while taking this medication A. I will need to remain upright for 1 hour after taking the medication pantoprazole is a proton pump inhibitor (omeprazole, lansoprazole) used to treat GERD by inhibiting gastric acid and pepsin secretion A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? Select all that apply. A. Sensation of tingling B. Decreased skin turgor C. Diminished capillary refill D. Pain relieved by analgesia E. Pale-colored toes A. Sensation of tingling C. Diminished capillary refill E. Pale-colored toes A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions? A. I will eat turkey sausage for breakfast B. I will use frozen vegetables rather than canned C. I like to use store bought spaghetti sauce D. I will put ketchup on my hot dogs B. I will use frozen vegetables rather than canned A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take? A. Assign the task to another AP B. Perform the task on behalf of the AP C. Report the AP to the risk manager D. Discuss with the AP concerns about performing the task C. Report the AP to the risk manager (?) A nurse is caring for a 2 year old child who has Clostridium difficile. Which of the following actions should the nurse take? A. Initiate contact precautions B. Use a N95 respirator C. Instruct the parents to avoid bringing fresh flowers into the room D. Place the child in a room that has a HEPA filtration system A. Initiate contact precautions A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following should the nurse include? A. Use confrontation to manage the client's behavior B. Limit the number of choices for the client C. Provide a stimulating environment for the client D. Use written signs to assist the client with locating the bathroom B. Limit the number of choices for the client A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the new nurse use when administering a transdermal patch? Select all that apply. A. Apply the patch to a clean, hairless area of the client's skin B. Remove the old transdermal patch before applying a new one C. Use sterile gloves to apply and remove transdermal patches D. Apply the transdermal patch to either of the client's forearms E. Dispose of old transdermal patches in a childproof container A. Apply the patch to a clean, hairless area of the client's skin B. Remove the old transdermal patch before applying a new one E. Dispose of old transdermal patches in a childproof container A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicate an understanding of the teaching? A. We can use petroleum jelly to keep his nares moist B. We will need to remove the nasal cannula when he is eating C. We will frequently check the top of his ears for sores D. We can turn the oxygen up to 10 when he has trouble breathing C. We will frequently check the top of his ears for sores A nurse is assisting with the care of a preschooler who has manifestations that suggest epiglottitis. Which of the following actions should the nurse take? A. Obtain a specimen for throat culture B. Collect a sputum sample C. Determine the preschooler's oxygen saturation level D. Inspect the preschooler's tonsils for edema C. Determine the preschooler's oxygen saturation level (?) A nurse is caring for a client who is confused and trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take? A. Fasten the restraint ties to the bed side rails B. Remove the restraints from the client's wrists every 2 hours C. Check that one finger will fit between the client's wrists and restraints D. Contact the provider within 48 hours to obtain a prescription for the restraints B. Remove the restraints from the client's wrists every 2 hours A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching? A. This procedure will take place while I'm under general anesthesia B. I will follow a full liquid diet the day before the procedure C. I will have my friend drive me home after the procedure D. I can expect rectal bleeding for a week after the procedure C. I will have my friend drive me home after the procedure A nurse is caring for a client who has chronic diarrhea. Which of the following findings should the nurse expect? A. Hypertension B. Respiratory acidosis C. Hypokalemia D. Hypermagnesemia C. Hypokalemia A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider? A. Bradycardia B. Weight gain C. Epistaxis D. Anorexia C. Epistaxis A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first? A. Minimize environmental stimuli in the client's surroundings B. Administer an anti-anxiety medication C. Explore behaviors that have helped to reduce the client's anxiety in the past D. Explain to the client that anxiety causes physical manifestations A. Minimize environmental stimuli in the client's surroundings A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take? A. Slow the rate of formula instillation B. Replace the NG tube C. Chill and readminister the formula D. Lower the head of the bed to 15 degrees A. Slow the rate of formula instillation A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take? A. Review the medical record to see if the client has reported abuse in the past B. Restrict family members from visiting with the client C. Contact the client's caregiver to discuss the client's comment D. Report the suspected abuse to the nurse manager D. Report the suspected abuse to the nurse manager A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching? A. My health care proxy designee is not able to sign a consent form on my behalf. B. Once my health care proxy is in place, I relinquish my right to make my own decisions. C. If I have a health care proxy, then I do not need to have a living will. D. I do not need to name a relative as my designee in my health care proxy. D. I do not need to name a relative as my designee in my health care proxy. Certification is the process through which: A. A nurse can advance through the clinical ladder B. VNs can gain phlebotomy, IV insertion and IV drug administration competency C. Nurses can automatically advance on the career ladder B. VNs can gain phlebotomy, IV insertion and IV drug administration competency The purpose of the state board of nursing are: (Select all that apply.) A. Approving schools of nursing B. Provide mentors for new graduates C. Reviewing and issuing licenses D. Protect the public by administering the Nurse Practice Act E. Monitoring turn-over of nurses in various facilities F. Suspend or revoke nurse licenses D. Protect the public by administering the Nurse Practice Act F. Suspend or revoke nurse licenses The nurse hears alarms and discovers the client is having shortness of breath (SOB) and the mechanical ventilator appears to be malfunctioning. Who will be dealing with this problem? A. The respiratory therapist B. The bio-engineer C. The physician D. The nurse D. The nurse A nurse is caring for a client who has dementia and is scheduled for a procedure. Which of the following individuals must sign the client's informed consent? A. The client's sister, who assists with finances B. The client's daughters, who is the primary caregiver C. The client's son, who has durable power of attorney D. The client, who has advanced directives C. The client's son, who has durable power of attorney In your job, you encounter a problem. Follow the chain of command and don't let the situation get out of hand. Remember that any problem is best solved by: A. Argument B. Agreement C. Communication D. Withdrawing C. Communication A nurse is caring for a client who is to undergo a total knee arthroplasty. Which of the following actions should the nurse take when participating in the informed consent process? A. Tell the client the names of health care providers who will participate in the surgery B. Inform the client of the possible outcomes if she does not receive treatment C. Explain the amount of pain the client will have following the procedure D. Verify the client is giving consent voluntarily D. Verify the client is giving consent voluntarily An older adult client falls and fractures her hip while a nurse is assisting her to the bathroom. The client sues the nurse for negligence. The nurse should identify which of the following principles of standards that will legally determine her liability for the client's injury? A. The client's provider testifies that the client's condition required a different method of moving her B. Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances C. An expert nurse describes how the nurse could have handled the same situation differently D. The plaintiff's attorney states that the nurse could have prevented the client's injury D. The plaintiff's attorney states that the nurse could have prevented the client's injury Since 2015, NCLEX test administrators revised the test format by including alternative format items including all but: A. Fill-in-the-blank questions including ordered-response questions B. Hot spot items in which an area, picture or graphic is determined C. Multiple correct answer questions D. Quick response essay questions D. Quick response essay questions Professional certification: A. For VNS includes OR nursing, pediatrics and gerontology B. Are available to VNs through seminars or self-guided study courses C. For VNs includes managed care, pharmacology and pediatrics D. Are not important to VNs aside from IV certification B. Are available to VNs through seminars or self-guided study courses The doctrine of informed consent means that the: A. Client must be given pertinent facts in professional and technical formal terms B. Client receives a brief outline of necessary facts before a surgery is performed C. Client must be given pertinent information regarding the benefits of an intervention, the risks involved, alternatives, etc. D. Client who refuses an invasive procedure, caregivers can have the family member consent instead C. Client must be given pertinent information regarding the benefits of an intervention, the risks involved, alternatives, etc. Which of the following actions will assist you map your strategy towards career planning? Select all that apply. A. Develop interviewing skills B. Develop a resume C. Call nurse recruiters D. Obtain additional training, if needed E. Record each step of your strategy F. Practice interviewing by role-playing with a mentor A. Develop interviewing skills B. Develop a resume E. Record each step of your strategy F. Practice interviewing by role-playing with a mentor The nurse should begin client rounds: A. After receiving change-of-shift reports and checking all patient charts for new orders B. At the beginning of shifts C. After patients are awake D. When the team leader asks them to B. At the beginning of shifts After signing an informed consent form, a client tells the nurse, "I have changed my mind and do not want to have the procedure." Which of the following actions should the nurse take? A. Proceed with the preparation of the client for the surgical procedure B. Tell the client to discuss the matter with her family C. Notify the surgeon that the client wishes to withdraw informed consent for the procedure D. Remind the client that a signed informed consent form is a legally binding document C. Notify the surgeon that the client wishes to withdraw informed consent for the procedure A nurse is assisting in preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following transcription examples should the nurse use? A. 0.2 mg B. 0.20 mg C. .2 mg D. 2.0 mg A. 0.2 mg The vocational nurse will expect the long-term care job interview to include: A. Qualifications and personality B. Psychological and spiritual development C. Propensity(?) for possible burn-out or chemical impairment D. Language skills and cultural background A. Qualifications and personality A long-term nurse who carries out an erroneous or inappropriate order that does not immediately harm the client: A. Is not responsible because there is no immediate harm B. Is not responsible for physician or pharmacy errors C. Has no risk of being held liable for the action D. Is responsible for the error and can be held legally liable D. Is responsible for the error and can be held legally liable A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information? A. An entry on a nursing blog addressing wound healing B. Information from a wound care product vendor C. First hand experience with wound care products D. A peer-reviewed journal article D. A peer-reviewed journal article A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate effectiveness of the program? A. Review the facility's policy and procedure manual B. Define the problem C. Identify data collection methods D. Perform chart audits A. Review the facility's policy and procedure manual A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of TPN. Which of the following actions should the nurse take? A. Use clean technique when changing the catheter dressing B. Prepare the client for a chest x-ray to verify catheter placement C. Place the client in sims position for catheter insertion D. Verify the amount of TPN solution the client is receiving every 4 hr B. Prepare the client for a chest x-ray to verify catheter placement A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feeding. Which of the following actions should the nurse take to monitor the AP's performance of the task? A. Instruct the AP to report back one task is complete B. Tell the AP to list the steps of the task C. Request the AP to provide a return demonstration of the task D. Ask the family if the AP performed the task correctly C. Request the AP to provide a return demonstration of the task A nurse is reinforcing discharge teaching with a patient who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team? A. Occupational therapist B. Social worker C. Physical therapist D. Primary care provider B. Social worker A nurse is reviewing the medical record of a client who has COPD. Which of the following findings should the nurse report to the provider? A. Temperature B. Fluid intake C. Sputum color D. Platelet count A. Temperature A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching? A. I can stop giving my child this medication if he is taking steroids B. I will give this medication to my child once daily in the evening C. It takes 2 months of scheduled use before this medication is effective D. I will give this medication to my child every 2 hours if he is wheezing B. I will give this medication to my child once daily in the evening A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? A. I will no longer be infectious after 30 days of treatment. B. I should throw away my used tissues in a closed plastic bag. C. I will need to take medication for this condition for the rest of my life. D. My family will need to wear a mask when around me at home. B. I should throw away my used tissues in a closed plastic bag. iron intake with citrus juices to increase absorption seasonal affective disorder (SAD) light therapy suppresses the natural melatonin left-hemisphere stroke difficulty with speech disulfiram (Antabuse) used for alcohol detoxification high risk of developing cancer weakened immune response manifestations of pulmonary tuberculosis (TB) night sweats, weight loss, anorexia fentanyl used to treat break-through pain expected findings for antisocial personality They disregard others' safety adverse effect of benzodiazepines sedation Stage 4 Alzheimer's The client is able to identify names of family members Type 2 Diabetes Mellitus (DM) cells are resistant to the effect of insulin An umbilical cord on child born 12 hours ago starts bleeding. What do you do? check integrity of the cord clamp What prevents dumping syndrome? eliminating simple sugars and alcohol purpose of phototherapy helps lower your newborn's bilirubin levels spinal anesthetic the nurse should infuse 500 mL of 0.9% sodium chloride prior Lyme disease after being bit by a tick expect a progressive circular rash risk for latex allergy allergic to bananas test taken at 35 weeks of gestation Group B Streptococcus B Hemolytic cultures methimazole (Tapazole) anti-thyroid agent; after long time use, decreases body temperature(?) intervention for deep vein thrombosis (DVT) legs elevated in bed promotes comfort and promotes circulation expected findings of a perforated peptic ulcer board-like abdomen A client has an ear infection. How should the nurse administer the antibiotic drops? Warm the drops to room temperature; have client lie on the opposite of the affected ear A school-aged child is diagnosed with cystic fibrosis. What is an appropriate diet for them? foods high in protein and fat cyclosporine immunosuppressant drug used to prevent organ transplant rejection; clients need to schedule a dentist appointment every 3 months electroconvulsive therapy (ECT) the client wakes up 15 minutes after the procedure; 2-3 treatments required a week; 6-12 treatments a month(?) expected finding of borderline personality disorder (BPD) self-mutilation a nurse's first action after birth dry the newborn cycloplegic drugs used during eye exams; causes temporary blurred vision infiltration causes edema and coolness; need to stop infusion collecting ABGs on a newborn careful when restraining newborn during the procedure antitussive used for a dry, nonproductive cough purulent exudate yellow thick drainage children who have rheumatic fever can take aspirin; results from inadequately treated strep throat or scarlet fever; manifestations include inflammation of the heart, blood vessels, joints, brain and skin interventions to reduce pain for migraines dark room; cool cloth on forehead bethanechol chloride (Urecholine) used for urinary retention; atropine sulfate used to counteract adverse effects A client receives fentanyl via epidural. What do you monitor? check O2 saturation and for hypotension systemic lupus erythematosus (SLE) inflammatory autoimmune disease that affects the joints, skin, kidneys, blood cells, brain, heart and lungs; take ibuprofen for joint pain post mastectomy avoid deodorant until drains are removed and the incisions heal streptococcal pharyngitis replace toothbrush 24 hours after antibiotics; gargle warm saline daily; can go back to school 24 hrs after antibiotics A client is recovering from a thyroidectomy and has harsh, high-pitched respiratory sounds. What should the nurse do? prepare for tracheostomy preparing a bottle for newborns mix 1 scoop of powdered formula with 2 oz of water highest risk factor for bladder cancer tobacco use manifestations of hyperglycemia and diabetic ketoacidosis fruity breath odor, dry mouth, extreme thirst 6 week infant should demonstrate a startle reflex by a loud noise (Moro reflex) sickle cell anemia interventions hydration and pain relief A client in labor received epidural and the fetal tracing shows late decelerations. What should the nurse do? position the client on her side indication of fat emboli chest petechiae albuterol short-acting beta agonist (SABA) used for acute asthma attacks Vitamin K helps prevent... intracranial hemorrhage in newborns bed to wheelchair transfer place the wheelchair at a 45 degree angle biceps reflex 2+ expected/normal; document manifestation of myocardial infarction nausea ethambutol used for TB; causes loss of red/green color discrimination contraindication to receiving a hepatitis B vaccination allergy to Baker's Yeast A client has cholecystitis. What should the nurse expect? Blumberg sign (rebound tenderness) famotidine histamine-2 receptor antagonist used to treat GERD and duodenal ulcers; report bloody stools otitis media feeling of fullness in the ear fluid volume excess the nurse should expect to hear crackles in the lungs acamprosate used for detoxification from alcohol; might cause episodes of diarrhea NG tube pH content should be 5 or less; placement checked with x-ray ventriculoperitoneal shunt drains excess CSF from the brain; post-operative check for abdominal distention doxycycline (Vibramycin) used for gonorrhea, chlamydia and syphilis; monitor for adverse effect of photosensitivity manifestation of hemolytic transfusion lower back pain finasteride urinary retention medication used to treat enlarged prostate (BPH); decrease in prostate-specific antigen (PSA) level manifestations of hypoglycemia weak and slurred speech diet for Celiac disease gluten free sulfasalazine sulfonamide used for UTIs, otitis media and diarrhea; review CBC prior to medication administration (causes blood dyscrasias) valproic acid (Depakene) taken for tonic-clonic, absence and myoclonic seizures; also for acute mania in bipolar disorder; causes changes in mood and behavior percutaneous endoscopic gastrostomy (PEG) tube feeding put patient in semi-Fowler position good sources of protein hummus and peanut butter chronic obstructive pulmonary disease (COPD) diet will eat more cold food than hot A client with cystic fibrosis has a prescription for daily chest physiotherapy. What is the purpose of it? to mobilize secretions in the airway A client has been using alprazolam for a long time. How should they discontinue the medication? taper the dose slowly over several months alprazolam is a benzodiazepine used for anxiety and also for anxiety associated with alcohol withdrawal tap water enema place client in left Sims position; lubricate 2 in of rectal tip nicotine lozenges used for smoking cessation; do not have more than 20 a day inserting an intravenous peripheral catheter apply anesthetic cream 60 min prior; 25 to 27 gauge catheter capillary fingerstick don't elevate the finger above heart level 20 weeks gestation the baby will be moving breast cancer metastasizes to the bones pyrosis heartburn 16 weeks gestation report urinary urgency to the provider A client is using a nitroglycerin sublingual tablet. Which statement indicates that the client understands teaching? I will sit when I take this medication. kidney stones treatment drink 4 quartz of water naloxone (Evzio, Narcan) opioid antagonist used to reverse respiratory depression from opioid agonists; adverse effect report of pain A client is to begin taking captopril for their hypertension. Which statements indicates client understanding? I might feel dizzy on this medication. pneumococcal immunization for people 65 years and older head injury treatment check for ABCs first and immobilize the client's cervical spine sanguineous drainage blood-tinged low-cholesterol diet remove skin from poultry indication of hearing loss of left ear air conduction is less than bone conduction in left ear respiratory syncytial virus (RSV) causes dehydration so prepare IV fluids if baby isn't eating opioid toxicity nursing priority ensure an adequate airway influenza vaccine given annually in the fall expected findings of anorexia nervosa amenorrhea A client is postoperative from a leg amputation. Which statement indicates the client's understanding? I will lie on my stomach for 30 mins a few times a day. restraints renew the prescription every 24 hours; remove at least every 2 hours hot flashes related to menopause patient should take black cohosh as a supplement mammogram annual starting at 40 years old A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take? Apply the external fetal heart rate monitor. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority? Lack of sleep A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse provide to help the client manage his symptoms? Eat a bedtime snack A nurse is reinforcing teaching for a client who has a coronary artery disease and is taking low-dose aspirin daily. The nurse should include that this medication has which of the following therapeutic effects for CAD? Antiplatelet A nurse is collecting data from a client who has an unprepared femur fracture and rates his pain as 8 on a scale of 0 to 10. The client is talking and caught with a visitor. Which of the following of the prescribed medication should the nurse administer? hydromorphone 5 mg orally A nurse is reinforcing preoperative teaching with a client scheduled for a bowel resection with ileostomy. Which of the following descriptions should the nurse give of the expected output from a mature ileostomy? Liquid with little odor A nurse is caring for a client who is 16 hr postoperative following a total hip arthroplasty. The client reports numbness, pain, and tingling in the affected leg. Which of the following actions should the nurse take first? Compare capillary refill in the toes bilaterally A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the teaching about the acute phase of diverticulitis? "I will receive the nutrients I need through my IV fluid." A nurse in reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk of cancer? Lamb A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the following modes should the nurse include as a method of transmitting hepatitis A? Consumption of contaminated food A nurse is reinforcing teaching with a client who is bottle feeding her full-term newborn with formula. Which of the following instructions should the nurse include in the teaching? Feed the newborn at least every 3 to 4 hr A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate. Which of the following interventions should the nurse include in the plan of care? Irrigate the bladder using sterile technique A nurse is reviewing a client's electronic medical record and finds that an assistive personnel recorded the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which of the following actions should the nurse take first? Check the client's temperature A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first? A client whose urinary output was 100mL for the past 12 hrs A nurse is reinforcing teaching about weight loss with a female older adult client who is overweight. Which of the following statements should the nurse include in teaching? Keep fat intake to no more than 30% of daily caloric intake A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect? Difficulty concentrating A nurse is collecting data from an older adult client who is 48 hr postoperative following abdominal surgery. The provider writes a prescription to advance the client to a regular diet. For which of the following findings should the nurse notify the provider? The client has absent bowel sounds A nurse is reinforcing discharge teaching with a client who is postoperative following transurethral resection of the prostate. Which of the following instructions should the nurse include in the teaching? Perform Kegel exercises daily A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following strategies should the nurse include in the teaching? Purchase beef that is a loin cut A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make? "You weight gain should be the same as for someone without diabetes." A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching? "I should offer my child yogurt that has a probiotic as a snack." A parent brings her adolescent son to an urgent care center and states, "He is high on something and needs help." The client is exhibiting agitation and paranoia and reports visual hallucinations. The nurse should suspect intoxication with which of the following substances? Methamphetamines A nurse notices an assistive personnel taking a nap in the break room during the meal time. The AP appears drowsy while performing routine tasks. Which of the following actions should the nurse take? Report the observations about the AP to the unit's nurse manager A nurse is reinforcing teaching with a client who has a fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving? Cherry tomatoes The nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions? Lateral recumbent A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states, "I really thought I'd be back to my usual routines by now, but I can't think of anything else except my son is gone." Which of the following responses should the nurse make? "Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss." A nurse is instructing an assistive personnel on the use of proper body mechanics when moving a client. Which of the following statements by the assistive personnel should the nurse identify as an understanding of the teaching? "I will use a pull sheet to help slide the client toward me." A nurse is collecting data from a female client who has a new diagnosis of genital herpes. Which of the following findings should the nurse expect? Painful erythematous vesicles A school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parents? "We can't decide whether to try to homeschool our child or move her to a private school." A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take? Use one finger to insert the suppository past the anal sphincters A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which of the following information should the nurse manager include in the in-service? Remove rings when washing hands with soap and water A nurse is reinforcing home safety instructions with the parents of a newborn. Which of the following statements should the nurse include in the instructions? "Place your baby's crib away from heat vents." A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity? Scan the client facility identification board While administering a medication to a client, a nurse notices a frayed electrical cord connecting the client's continuous passive motion machine to the electrical outlet. Which of the following actions should the nurse take? Remove the device from the client's room A nurse is caring for a client who requests information bout advance directives. Which of the following responses should the nurse make? "Advance directives are written instructions regarding end-of-life care." A nurse is contributing to the plan of care for a client who is at risk of developing pressure ulcers. Which of the following actions should the nurse include in the plan of care? Place the client in a 30° lateral position A nurse is reinforcing discharge teaching with a client following cataract surgery. Which of the following instructions should the nurse include in the teaching? Sleep on the nonoperative side for 2 weeks A nurse manager is preparing to complete a performance analysis for a group of assistive personnel. The manager asks a staff nurse for feedback on each assistant's abilities. Which of the following actions should the staff nurse take? Discuss how each AP's actions measure against the job description A nurse is preparing to administer a medication to a client when the client states, "I'm sick of all these medications. I'm not taking any more today!" Which of the following actions should the nurse take? Inform the client of the possible consequences of the medication refusal A nurse is reinforcing teaching for a preoperative client on how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching? The client attempts to elevate the cylinder by inhaling deeply A nurse at a long term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality? The facility had 12% fewer urinary tract infections over the past 6 months A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose? Creatinine 2.5 mg/dL Normal range for creatinine is 0.6-1.2 mg/dL for males and 0.5-1.1 mg/dL for females. This value is too high and indicates nephrotoxicity, an adverse effect of aminoglycosides like gentamicin and streptomycin. A nurse working in a community clinic is caring for an adolescent who has infectious mononucleosis. The client asks the nurse to explain how the disease was acquired. The nurse should explain that an individual acquires this disease by which of the following? Sharing eating utensils with an infected person A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching? "You will need to take the medication for the rest of your life." A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider? Client reports burning with urination A nurse is reinforcing reaching with a client about a planned thoracentesis. Which of the following information should the nurse include in the teaching? "You will need to be monitored for 1 hour after the procedure." A licensed practical nurse on a medical surgical unit is working with a RN and an AP. Which of the following assignments should the LPN expect to receive? Administering an NG tube feeding to a client who had a stroke A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take? Offer the client headphones to listen to music A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching? "If I forget to take a dose, I can take it later on the same day." A nurse is working with an interpreter to explain a diagnostic procedure to a client who doesn't speak the same language as the nurse. Which of the following actions should the nurse take? Ensure the interpreter is culturally compatible with the client A nurse is contributing to the discharge plan for a client who had a knee arthroplasty. Which of the following actions should the nurse identify as the priority? Check the client's mobility A nurse is collecting data from a client who is 24 hr postoperative from an open colon resection, has a clamped NG tube, and is resuming a clean liquid diet. Which of the following findings should the nurse report to the provider? Client reports vomiting green-tinged fluid A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client? acetylcysteine A nurse delegates the collection of a sputum specimen from a client who has tuberculosis to an assistive personnel. At which of the following times should the nurse instruct the AP to collect the specimen? As soon as the client wakes up A nurse in a long term care facility is using validation therapy with a client who has dementia. The client becomes agitated and asks why his wife who died several years ago has not visited him. Which of the following responses should the nurse make? "You must miss your wife. Let's take a walk and you can tell me about her." A nurse is caring for a client who is postoperative following an open reduction with internal fixation of the ankle. The client reports pain and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical assistant who responds, "It has always been like that." Which of the following actions should the nurse take first? Notify the nursing supervisor A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally 3 times a day at home. Which of the following components of the prescription should the nurse question? Dosage A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take? Wipe the drainage port with an antiseptic wipe after emptying urine from bag A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions? "I will give our baby sponge baths until the cord falls off." A nurse who is facilitating a support group notices that one client in the group is extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the following strategies should the nurse use to facilitate the group process with this client? Speak privately to the client about this behavior A nurse at a clinic is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation? Lack of change in pupil size when the client looks from a far to a near object A nurse is reinforcing teaching with a client who has cancer and a new prescription for fentanyl transdermal patches. Which of the following statements by the client indicates an understanding of the teaching? "I will fold the patch with the adhesive sides inward before discarding it." A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hours ago and has a 4th degree perineal laceration. Which of the following actions should the nurse recommend? Instruct the client to use a sitz bath at least twice a day A nurse is collecting data from a client who sustained spinal cord injuries from fractures to the T1 and T2 vertebrae. Which of the following client outcomes should the nurse expect? Flexes and extends the shoulders A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take? Avoid massaging the site after injecting the vaccine A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation? "I should use counterpressure for back pain during labor." A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client? Offering general leads A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider? metoprolol ER 50 mg per NG tube BID A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the following foods should the nurse include in the plan as having the highest amount of iron? Boiled spinach A nurse is administering lorazepam to a client who is scheduled for surgery within 1 yr(?). Which of the following actions should the nurse take after administering the medication? Instruct the client not to get out of bed A nurse is observing an AP caring for a client. For which of the following actions should the nurse intervene? An AP reports client information to the oncoming AP in the hallway A nurse is observing a stable preterm newborn who develops apnea for longer than 20 sec, with a decreased heart rate of 20/min. Which of the following actions should the nurse take first? Flick the sole of the newborn's foot A nurse is caring for a client who is 4 hr postoperative following a total thyroidectomy. Which of the following manifestations should the nurse report to the provider as indicating possible hypocalcemia? Tingling of fingers A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault? Informing a client the nurse is going to administer an injection even though the client refuses A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first? "Where is your pain located?" A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. For which of the following results should the nurse notify the provider? Platelet count 95,000 mm3 A nurse is speaking with the adult daughter of a client who has Alzheimer's disease. The daughter states, "I love my dad, but caring for him is wearing me out." Which of the following responses should the nurse make? "Let's discuss how caring for your father is affecting your health." A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following actions should the nurse include in the plan of care? Maintain the drainage system below the level of the client's chest A nurse is admitting a client who is at high risk for suicide. Which of the following actions is the nurse's priority? Search the client's personal belongings A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return? Maintain the sequential compression device A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take? Report the suspected abuse to an appropriate agency A nurse is collecting data from a middle adult female client who is taking melatonin. Which of the following responses to the medication should the nurse expect? Improved sleep A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention? A school-age child who has allergic rhinitis and is taking diphenhydramine diphenhydramine (Benadryl) is an antihistamine used for allergic rhinitis and conjunctivitis. Adverse effects include urinary retention, sedation, dry mouth, stuffy nose and constipation. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected TB. Which of the following actions should the nurse plan to take? Ensure the injection produces a wheal on the skin A client who is diagnosed with Parkinson's disease verbalizes frustration due to increased difficulty with ambulation. Which of the following responses should the nurse take? "Perform active ROM with your arms and legs two times a day." A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist? "I am so frustrated. I cannot even open my milk carton for breakfast." A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse? Reports lack of appetite A nurse is caring for a client who has a Penrose drain. To ensure proper placement and functioning of the drain, which of the following should the nurse expect to observe? The safety pin is present at the distal end of the drain A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants? Poor lighting in the learning setting A nurse is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula? Hydrogen peroxide A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching? "I will apply diaper cream to my baby's skin during each diaper change." Rotavirus causes severe, watery diarrhea and vomiting in infants and young children. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though he has already signed the informed consent form. Which of the following actions should the nurse take? Report the situation to the provider who obtained the informed consent A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report? The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, "I don't think I can go through this again." Which of the following actions is the nurse's priority? Determine if the client is experiencing psychotic thinking A nurse is reinforcing discharge teaching with a client who is 48 hr postoperative from a mastectomy. Which of the following statements by the client indicates an understanding of the teaching? "I will wear rubber gloves whenever I wash dishes or do yard work." A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school age child. Which of the following information should the nurse include? Separate the child's used washcloth from those of others A nurse is collecting data from an older adult client during a routine physical exam. Which of the following client statements should the nurse identify as a possible indication of abuse? "My son took my wallet so he can keep track of what I'm spending." A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit? Have a supply of prescribed medications A nurse is reinforcing teaching on food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in Vitamin C? Tomatoes A nurse on a medical surgical unit is delegating tasks to an assistive personnel. Which of the following tasks should the nurse delegate to the AP? Obtaining a client's vital signs prior to discharge A nurse in a long term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following actions should the nurse plan to include? Change the appliance two times each week A nurse is receiving report on 4 clients. Which of the following clients should the nurse plan to see first? A client who has pneumonia and a new onset of confusion A nurse is reinforcing discharge teaching with a client who has a T-tube in place following a cholecystectomy. Which of the following instructions should the nurse include in the teaching? Empty the drainage bag each day at the same time A nurse is preparing to insert an indwelling urinary catheter for a female client who has a urinary retention. Which of the following actions should the nurse take? Open the outer package flap of the catheterization kit away from her body A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following communication methods should the nurse use? Provide a picture board A nurse is caring for a client who is NPO and has an NG tube attached to suction for gastric decompression. Which of the following actions should the nurse take if the client experiences abdominal distention? Irrigate the tube with normal saline A nurse is assisting with admitting a client who has colorectal cancer. When collecting data from the client, which of the following manifestations should the nurse expect? Abdominal cramps A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication is effective? Cardiac workload decreases A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make? "Your oncologist may prescribe a cold cap to wear during treatment to reduce hair loss." A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching? "I will imagine myself in a calm place when I can't concentrate." A nurse is caring for a female client during an outpatient clinic visit. Which of the following findings places the client at risk for coronary artery disease? The client's LDL level A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonography the following day. Which of the following statements should the nurse include in the teaching? "You will need to have a full bladder for the procedure." A nurse is reviewing the plan of care for a client who is 3 hr postoperative following a thyroidectomy. Which of the following is the priority intervention? Listen to the client for evidence of stridor A nurse in a long term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include? Prolonged use of corticosteroids is a risk factor for infection A nurse is collecting data on a client who has post traumatic stress disorder. Which of the following manifestations should the nurse expect? Hypervigilance A nurse is caring for a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Ataxia Ataxia is the presence of abnormal, uncoordinated movements; impaired balance A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider? Heart rate 146/min Normal heart rate for a preschooler (ages 3-5) is 80-110/min A nurse is preparing to discharge a middle adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer? Pneumococcal polysaccharide (PPSV) vaccine This vaccine is given to adults 65 years and older A nurse is caring for a client who had a bone marrow transplant 3 days ago for treatment for leukemia. Which of the following findings should the nurse identify as a safety hazard? A visitor brought the client a bouquet of flowers A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to therapy? Moist mucous membranes A nurse at a long term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse? ​potassium chloride 20 mEq PO every morning A charge nurse in a long term care facility notices an assistive personnel's repeated failure to provide oral care for clients. Which of the following actions should the nurse take? Discuss the unacceptable behavior with the AP while reinforcing expectations A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (Select all that apply.) A pharmacist Package inserts American Diabetes Association A nurse is caring for four clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possesses effective time management skills? (Select all that apply.) Gathers all needed supplies and equipment before entering client rooms Completes one task before beginning a new task Documents the clients' preoperative vital signs when they are taken Delegates tasks to an assistive personnel (AP) that are within his range of function A nurse in a long term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.) Determine the facts related to the dilemma Identify possible solutions Consider the client's wishes A nurse is assisting with the admission of a client who has a latex allergy. The nurse should identify which of the following supplies has the potential to contain latex? Indwelling urinary catheter A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take? Gently close the client's eyelids A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client? chlordiazepoxide chlordiazepoxide is a benzodiazepine used to relieve anxiety and control agitation caused by alcohol withdrawal A nurse is contributing to the plan of care for a client who is postoperative following a rhinoplasty. Which of the following interventions should the nurse recommend? Instruct the client to avoid the Valsalva maneuver Examples of the Valsalva maneuver include straining during defecation; when you breathe out strongly through your mouth while holding your nose tightly closed A nurse is assisting with a community education program for parents of preschoolers about recommended activities to promote physical development. Which of the following statements should the nurse make? "You should provide unorganized play activities for your child each day." A nurse is assisting with the care of a client who is postpartum and has deep vein thrombosis. The client has been receiving heparin via IV infusion. Which of the following medications should the nurse ensure is readily available? protamine sulfate A nurse is collecting a urine specimen from a female client who has diabetes insipidus. The nurse should expect which of the following findings? Urine specific gravity of 1.002 Normal specific gravity is 1.005-1.030. A client with diabetes insipidus will not have a normal value due to the dilute urine A nurse is collecting data from an older adult client who has a hip fracture. Which of the following findings should the nurse expect? External rotation A home health nurse is collecting data from a older adult client who has generalized anxiety disorder. The client lives at home with her partner and a sibling. Which of the following responses by the client's partner is the priority for the nurse to address? "Her prescription isn't generic, so we can't afford it anymore." A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this method of pain control? "I should report leaking at the insertion site to the anesthesiologist." A nurse is caring for a newborn who is 1 hr old. The mother received fentanyl 30 min before delivery. For which of the following adverse effects should the nurse monitor the newborn? Respiratory distress A nurse is assisting with an educational program about car restraint safety for a group of parents. Which of the following statement indicates understanding of the instructions? My 12 year old should place the shoulder lap seatbelt low across his hips A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. The nurse should report to the provider which of the following findings as an indication of hyperglycemia? Polyuria A nurse is monitoring a school-age child who has anemia and is receiving a transfusion of packed RBCs. Which of the following statements by the child indicates a possible hemolytic transfusion reaction that the nurse should report to the charge nurse and the provider? "I am really cold. May I have another warm blanket?" A nurse is reviewing laboratory results for a client who is receiving mechanical ventilation. Which of the following findings should the nurse recognize as a potential complication of mechanical ventilation? pH 7.5 A nurse is contributing to the plan of care for a client who has a prescription for range of motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension? Move her arm behind her body with her elbow straight The nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. Which of the following statements should the nurse make? You should increase your fluid intake after this procedure. A nurse is caring for a newborn who is 12 hr old. Which of the following stools should the nurse instruct the parents to expect during the first 24 hr after birth? Dark green and viscous A nurse in a provider's office is reinforcing teaching with client who is to follow a 2000 mg sodium-restricted diet. Which of the following client food selections indicates an understanding of the teaching? Canned peaches A nurse is contributing to the plan of care for the client who has pneumonia. Which of the following entries should the nurse include in the plan? Client prefers to shower in the evening. A nurse is assisting with the plan of care for a client who has continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination? Use intermittent urinary cauterization for the client at regular intervals A nurse is documenting client care in the medical record. Which of the following entries should the nurse make? Client remains NPO until x-ray procedure is completed. A nurse is contributing to a teaching plan for a group of male adolescents about the adverse effects of anabolic steroid use. Which of the following manifestations should the nurse include? Reduced height potential A nurse is assisting with the care of a school-age child immediately following surgery. The child weights 21.8 kg (48 lbs) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider? 250 mL of sanguineous drainage over the last 3 hr A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? Coronary artery disease A nurse is assisting with the planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care? Administer atropine to reduce the client's respiratory secretions atropine is used to treat symptoms of bradycardia, reduce salivation and bronchial secretions before surgery or as an antidote for overdose of cholinergic drugs A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following indicates the client is experiencing a therapeutic response to the medication? Reports a decrease in the number of stools A nurse is assisting with the admission of a client who has rubeola. Which of the following transmission-based precautions should the nurse plan to initiate for this client? Airborne Rubeola = measles A nurse is instructing an assistive personnel about caring for an older adult client who has herpes zoster. Which of the following information should the nurse include? The infection is contagious until the blisters heal. A nurse in a long-term care facility is documenting the care of an older client. Which of the following information should the nurse include in the weekly nursing care summary? Hydration status A nurse is planning to administer nystatin oral suspension to a client who has oral candidiasis. Which of the following instructions should the nurse give the client? Hold the medication in your mouth several minutes prior to swallowing. A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include? "You should increase your fluid intake while receiving this medication through the PCA pump." A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first? Check for documentation that the provider spoke with the client about the DNR A nurse is caring for a client who is at 34 weeks of gestation and has mild preeclampsia. Which of the following findings indicates a progression from mild to severe preeclampsia? Client reports of blurred vision A nurse is caring for a client who is scheduled for peritoneal dialysis. Which of the following actions should the nurse take first? Ensure the dialysate solution is at room temperature A nurse is caring for a 3 year old toddler at a well child visit. The parent states that the child will not eat a full meal. Which of the following responses should the nurse make? Offer healthy snacks frequently, rather than expecting him to eat full meals A nurse is caring for a client who is 4 hr postoperative following a gastrointestinal surgery and has an NG tube for gastric decompression. Which of the following actions should the nurse take? Keep the plugged tube above the level of the stomach when the client is ambulating A nurse is assisting with an educational session for newly licensed nurse about intimate partner violence. Which of the following characteristics should the nurse include as placing a vulnerable person at risk for intimate partner violence? Recent confirmation of pregnancy A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider? Muscle pain atorvastatin is a HMG-CoA reductase inhibitor used to reduce liver cholesterol. Serious adverse effects of these include myopathy, rhabdomyolysis, liver dysfunction and myoglobinuria A nurse is assisting with a discussion about STIs with a group of adolescents at a health fair. Which of the following statements should the nurse make? An infection with gonorrhea may result in infertility. A nurse is assisting with the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse include in the plan of care? Place the client in the private room A nurse is reinforcing teaching with a client who has alcohol use disorder and is to begin disulfiram therapy. Which of the following statements should the nurse make? "You will need to sign an informed consent form before starting this medication." A nurse is reinforcing teaching with an older adult client who has osteoarthritis . Which of the following instructions should the nurse include? Apply capsaicin cream four times daily capsaicin is used to treat aches and pains of the muscles and joints as in arthritis, backaches and sprains A nurse is reinforcing teaching with a female client who has TB and a new prescription for rifampin. Which of the following statements by the client indicates understanding of the teaching? I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant. rifampin is an anti-tubercular agent. An adverse effect is that it decreases the effectiveness of oral contraceptive pills. A nurse is reinforcing teaching with a client who has asthma and has a prescription for theophylline. Which of the following statements should the nurse make? Discontinue drinking caffeinated beverages. The nurse is preparing to insert an indwelling catheter for a female adult client. Which of the following actions should the nurse take? Select all that apply. Cleanse the client's labia and meatus using a front-to-back motion. Use the nondominant hand to expose the client's urinary meatus. Advance the catheter 5 to 7.5 cm (2 to 3 in) into the client's urinary meatus. Ask client to bear down while inserting the catheter. A nurse in an urgent care clinic is caring for a child who has a minor burn on his palm after touching the burner on a hot stove. Which of the following actions should the nurse take? List the steps in order. Clean the burn with mild soap and tepid water Remove any embedded debris Apply an antimicrobial ointment Wrap the hand in a gauze dressing Inform the parent of dressing change schedule A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique? Putting a glove on their dominant hand first A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of the following manifestations should the nurse expect? Hematemesis A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration? zolpidem zolpidem is CNS depressant and a sedative used for insomnia A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching? Walk for 1-2 hrs each day A nurse is transferring a client from a bed to a wheelchair. The client has right-sided weakness following a recent stroke. Which of the following actions should the nurse take? Place the wheelchair on the client's left side A nurse is reinforcing teaching with a client who has asthma and a new prescription for an ipratropium inhaler. Which of the following statements by the client indicates an understanding of the teaching? "I should wait 1 minute before taking a second puff of the medication." A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider? Decreased bowel sounds A nurse is reinforcing teaching with the adult children of a client who is dying. Which of the following statements should the nurse make? "You can continue talking to your partner until they are gone." A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment? The child was born at 34 weeks of gestation A nurse is reinforcing teaching with a client who is scheduled for a barium enema. Which of the following statements should the nurse make? This procedure uses diagnostic imaging to locate an obstruction. A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I should apply sterile saline to lubricate the suction catheter." A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider? Irritability A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure? Confusion about knowing their own name A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect? Capillary refill of 5 seconds to the client toes A nurse is reinforcing teaching with a group of clients about the Heimlich maneuver during a first-aid class. The nurse should include in the teaching that which of the following manifestations indicates the need for the Heimlich maneuver to be performed? (Select all that apply.) Difficulty breathing Coughing Presence of stridor A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects? Gastric ulcer formation prednisone is a glucocorticoid "steroid" used for its anti-inflammatory, antiallergenic and immunosuppressant qualities. Adverse effects include peptic ulcer formation, delayed wound healing, hyperglycemia, osteoporosis and Cushing's syndrome (from long-term use) A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include? Apply the prosthesis immediately upon waking each day A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first? Perform a fundal massage for the client A nurse is caring for a client with diabetes mellitus who has an order for daily morning insulin before breakfast. The client refuses to get his blood glucose checked at 7:00 AM. Which of the following actions should the nurse take? Reinforce client teaching A nurse in a long-term care facility is reviewing a clients laboratory results. The client's potassium level is 5.8. Which of the following findings should the nurse expect? Abdominal cramps A nurse is collecting data during a well child visit of a 12 month old infant. Which of the following statements made by the parents indicates the need for further evaluation? "My child can't go from a lying to a sitting position." A nurse is caring for a child who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect to find at the insertion site? Edema A nurse is reinforcing discharge instructions regarding umbilical cord care to a mother of a newborn. Which of the following statements by the mother indicates teaching was effective? "I will wait until the cord falls off to give my baby a tub bath." A nurse in a long-term care facility is planning to perform hygiene care for a newly admitted male client with Parkinson's disease who is ambulatory. Which of the following is an appropriate statement by the nurse prior to starting routine care? "Do you usually take your bath in the morning or in the evening?" A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using? Rationalization A nurse is reinforcing teaching with the new mother of a full-term newborn about breastfeeding. Which of the following statements by the mother indicates an understanding of the teaching? "I should have my baby latch onto my nipple and areola during feeding." A nurse is reinforcing teaching to a parent of a child who has been prescribed ferrous sulfate in liquid form. Which of the following statements by the parent indicates the teaching was effective? "I will give the iron through a straw." A nurse is reinforcing teaching to a group of adolescent males. Which of the following statements made by the student indicates a need for further teaching? "I should perform as self exam of my testes once a year." An infant is admitted to a pediatric unit following a motor vehicle crash with a subsequent head injury. For which of the following should the nurse monitor to identify increased intracranial pressure? Decreased motor response A nurse is caring for a client who is terminally ill and requires ongoing palliative care. Which of the following interventions is consistent with the goals of this type of care? Allowing the family overnight visitation A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following actions should the nurse take? Instruct the client to take slow deep breaths A newly admitted client tells the nurse that he does not have an advance directive. Which of the following is appropriate action for the nurse to take? Provide the client with written information about advance directives A nurse is observing a client who is in the manic phase of bipolar disorder. The client states, "Don't need to eat today. Where is the money? Time to write the speech." The nurse to document this as which of the following? Flight of ideas A nurse is planning to have a client who is six hours postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's care plan? Place a pillow under the client's surgical knee A nurse is caring for a client who was recently diagnosed with paranoid schizophrenia and is taking risperidone. Which of the following statements by the family indicates a need for further teaching? "Our son's symptoms will stop as soon as he begins his medications." A nurse is caring for a newly postoperative client who has unilateral breath sounds and asymmetrical chest expansion. The nurse should recognize these findings are indicative of which of the following and will be reported to the provider? Atelectasis A nurse is planning care for client with delirium. Which of the following should the nurse recognize as interfering with the clients recovery? Provide the client with activities that vary daily A nurse is monitoring a client who is in labor. Which of the following findings needs further evaluation? Uterine contractions lasting 100 to 120 seconds A nurse observes a client who has Alzheimer's disease and is experiencing aphasia. Which of the following behaviors should the nurse suspect? Difficulty understanding spoken words A nurse is caring for a client experiencing alcohol withdrawal. Which of the following medications should the nurse anticipate administering? lorazepam (Ativan) A nurse is caring for a client who has borderline personality disorder. The client states, "I look forward to seeing you in the morning because the night nurse treats me badly." Which of the following behaviors is the client likely demonstrating? Splitting A nurse is planning a health promotion program for high school students. Which of the following facts about cigarette smoking is likely to be most effective in changing the adolescent's attitudes towards smoking? Smoking causes unattractive stains on the teeth and hands A nurse is caring for school age child whose family adheres to a vegan diet in the home. The nurse recognizes the child is at risk for deficiency of which of the following? Vitamin D A nurse is reinforcing teaching about levothyroxine (Synthroid) to a client who has hypothyroidism. Which of the following should the nurse instruct the client to report? Weight loss A nurse is reinforcing teaching for a client regarding various forms of contraception. The nurse should recognize that the client understands the instructions if she says, "I will..." Use a spermicide with condoms to increase the effectiveness A nurse is reinforcing teaching with a client diagnosed with diabetes mellitus requiring insulin injections. Which of the following statement made by the client indicates understanding of the teaching? "I shall remove bubbles from this syringe before injecting my insulin." A client newly diagnosed with bipolar disorder asks the nurse, "How long will I have to take lithium?" Which of the following is an appropriate response by the nurse? Medication is usually continued for six months after the symptoms subside A nurse is in the birthing unit is assisting with the care of a client who is at 38 weeks gestation and has bright red vaginal bleeding but denies pain. What does this indicate? Placenta previa A nurse is reinforcing teaching regarding the dietary intake needed to reduce the risk of neural tube defects with a client who is planning to become pregnant. Which of the following is a good source of folate? Cooked spinach The parent of a three-year-old child tells the nurse that he is concerned because his daughter has began playing with an imaginary friend. Which of the following is an appropriate response by the nurse? "This is a common behavior for children of this age." A nurse is reinforcing teaching regarding home care with a client who is scheduled for discharge following a coronary artery bypass graft. The client understands teaching when he says... "I can begin my cardiac rehabilitation program within a week." A mother of two small children tells the nurse, "I just don't know what to do about my cancer. I have seen three doctors and each one recommended a different treatment option." An appropriate response by the nurse would be: "Arranging a conference with your provider is something I can assist you with." A nurse is reinforcing discharge instructions for all the adult clients regarding management of hypertension. Which of the following should the nurse instruct the client to do when evaluating for the presence of the orthostatic hypotension? Take a blood pressure reading while sitting and another one two minutes later while standing A nurse is reinforcing teaching with a client who is scheduled to undergo a fiberoptic bronchoscopy. Which of the following clients statement indicates an understanding of the procedure? "They will look into my lungs with a lighted tube to determine my problem." A nurse is collecting data from a client who is pregnant and has hyperemesis gravidarum. Which of the following findings should the nurse expect? Decreased blood pressure A nurse is caring for postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first? Repeat the test on another finger A nurse is managing a client who is receiving a unit of packed red blood cells. The nurse recognizes an allergic reaction when the client reports... Urticaria A clinic nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following laboratory values should the nurse report to the provider? Urine protein 3+ A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asked if the provider can force her to have the treatment. An appropriate response by the nurse would be: "You have the right to refuse the recommended treatment plan." A nurse is caring for a client receiving packed RBCs. Which of the following findings should the nurse recognize as indicative of excess fluid volume? Crackles in the lung bases A nurse is caring for a client who was placed in a cast 12 hour ago due to a fracture of the left tibia. Which of the following findings is the highest priority? Numbness in the left foot A nurse is collecting data from a female client who wishes to begin oral contraception. Which of the following is a contraindication to the use of oral contraceptives? Current use of nicotine A nurse is reinforcing teaching to a client who is scheduled for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the teaching? "I will receive sedation prior to the procedure." A nurse finds the client's wife crying in the hallway. She states, "I just don't know how I'm going to go on after he's gone." Which of the following is an appropriate response by the nurse? "Tell me more about how you are feeling." A nurse is caring for a client whose previous blood pressure reading has been within the expected reference range. The client's current blood pressure reading is suddenly elevated above the expected range. Which of the following factors can contribute to a false blood pressure reading? The blood pressure cuff is too small for the client's arm A nurse is caring for a client who is experiencing respiratory acidosis. The nurse should expect which of the following serum pH levels? pH 7.30 A woman who is postmenopausal presents to a clinic for a well-woman examination. She tells the nurse that she does not understand the need for a Pap test because she's no longer experiencing menses. Which of the following responses by the nurse is appropriate? A Pap test can help with early detection of cervical cancer. A nurse is collecting data from a client who is in her third trimester of pregnancy. During a routine prenatal visit to the doctor's office, the client reports she feels dizzy, has clammy skin and becomes pale while lying down. The nurse should tell the client that when she feels this way she should do which of the following? Lie on her left side The nurse is to monitor a client who is taking furosemide (Lasix) for which of the following adverse effects? Hypokalemia A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings is to be expected? Dependent edema A nurse is reinforcing teaching to an adult client who is prescribed atorvastatin (Lipitor). The nurse should advise the client that which of the following adverse effects should be reported to the provider? Unexplained muscle pain A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel? Ambulating a client receiving patient-controlled analgesia (PCA) A nurse is working on a unit for a client with dementia. Which of the following client situations requires the nurse to write an incident report? A client is found lying on the floor next to the chair The nurse is discharging a client who was admitted for a new diagnosis of diabetes mellitus type two. The client is independent and lives alone. Which of the following should be included in the discharge plan? Refer the client to a diabetic support group A female client who is in an abusive marriage has discussed with a nurse strategies to prevent this abuse. Which of the following client statements indicates an understanding of an appropriate strategy? I need to recognize the signs that my husband is becoming abusive OR I need to identify what triggers my husband's anger to prevent his abuse A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observed that the assistive personnel has not documented the client's blood glucose level. Which of the following actions should the charge nurse take first? Determine if the AP has completed the assignment A client is scheduled for an outpatient colonoscopy. Which of the following actions is a nursing responsibility in the informed consent process? Verify there is a signed and witnessed consent form in the client's chart A nurse smells alcohol on the breath of an assistive personnel during report. Which of the following actions should the nurse take? Report the situation to the nurse manager A nurse from a medical surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept? A client who had a cesarean delivery 24 hours ago A nurse in the provider's office is collecting data from a parent of an infant who has been screened for cystic fibrosis. Which of the following support a diagnosis of cystic fibrosis? Frothy stool A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following action is appropriate for the nurse to take? Contact security personnel to place the money in the facility safe A nurse is caring for a client who is receiving heparin. Which of the following is an appropriate route of administration? Subcutaneous A nurse is caring for a client who had a femoral popliteal bypass graft two days ago. When monitoring peripheral pulses, the nurse is unable to locate the pulse on the affected leg. Which of the following actions should the nurse take? Notify the charge nurse of the finding A nurse is caring for a full term newborn who was circumcised six hours ago. Which of the following findings indicates that the newborn is experiencing pain? Furrowed brow A nurse is reinforcing teaching with the client about organ donation. Which of the following client statements indicates a need for further teaching? "My doctor should decide if my organs will be donated." A client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take this medication because it makes me tired all the time." Which of the following is an appropriate response? "Let's talk with your doctor about other options." A nurse is contributing to the discharge plan for a client following surgery. Which of the following findings indicates the need for an interdisciplinary care conference? The client requires assistance to pay for dressing supplies A client who is 24 hour postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis and cough. Which of the following actions should the nurse take first? Elevate the head of the client's bed A nurse is caring for a 17-year-old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent? Obtain verbal consent from the client while waiting for the parents to arrive A nurse is caring for a client admitted with a shortness of breath who will be undergoing arterial blood gas testing. Which of the following client statements indicates an understanding of the purpose of drawing arterial blood gases? "This would indicate how much acid is building up in my blood." A nurse is collecting data from a client who reports recent weight loss and a chronic cough that is producing blood-stained sputum. Which of the following should the nurse expect the client to have diagnostic testing for? Lung cancer A nurse is reinforcing teaching for a client admitted with an acute myocardial infarction. Which of the following activities is appropriate for the client to participate in during the first two weeks following discharge? Walking A nurse is caring for a client who is receiving warfarin (Coumadin) for deep vein thrombosis. The nurse observes that the client's INR is 3.8. Which of the following actions should the nurse take? Withhold the ordered dose of the medication Normal INR is 0.8-1.1 If the client requires anticoagulation, the desired value is increased to approximately 2-3