407 INTEGRATIONRN Comprehensive Online Practice 2019 B FINAL
1. A nurse is assessing a client who received 2 units of packed RBCs 48 hr. ago. Which of the following findings should indicate to the nurse that the therapy
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407 INTEGRATIONRN Comprehensive Online Practice 2019 B FINAL
1. A nurse is assessing a client who received 2 units of packed RBCs 48 hr. ago. Which of the following findings should indicate to the nurse that the therapy has been effective?
a. Hemoglobin 14.9 g/dl
b. WBC count 12000/mm3
c. Potassium 4.8 mEq/L
d. BUN 18 mg/dl
2. A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?
a. An older adult client who reports constipation of 4 days.
b. A preschooler who has a skin rash.
c. An adolescent who has a closed fracture
d. A middle adult client who has unstable vital signs.
3. A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
a. Palpate the degree of edema
b. Regulate IV pump fluid rate.
c. Measure the client’s daily weight.
d. Assess the client’s vital sign.
4. A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weights 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
a. 18 G
5. A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?
E. La foto que está parado de frente y solo se ven pies que están separados uno del otro hacia afuera. The image, on the adolescent is abducting the hip joint by moving the leg away from the midline of the body. (imagen with patient facingyouwithherrightleglifted) answerquizlet (es la imagen con el paciente frente a usted con la pierna derecha levantada).
6. A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?
a. Dry, coarse hair
b. Bradycardia
c. Tremors
d. Periorbital edema
7. A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect?
a. Nuchal rigidity
b. Weight gain
c. Tinnitus
d. Positive Trendelenburg sign.
8. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take?
a. Assess the apical pulse is most accurate when the newborn is in a quiet state. The sound of crying obscures the heart sounds.
b. Palpate the radial pulse for 30 seconds.
c. Listen to the apical pulse while palpating the radial pulse.
d. Auscultate the apical pulse at least 1 min.
9. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?
a. Administer a bowel preparation the night before the procedure.
b. Place the client on bed rest for 24 hr after the procedure.
c. Perform pulmonary function tests following the procedure.
d. Instruct the client to avoid coughing during the procedure.
10. A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?
a. A child exhibits discomfort while walking.
b. The child has thin extremities.
c. The child has bruises on the upper back.
d. The child is wearing a stained shirt.
11. A nurse is preparing to teach about dietary management to a client who has Crohn’s disease and an entero-enteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?
a. Calories
b. Protein
c. Potassium
d. Fiber.
12. A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
a. Turn off the CPM machine during mealtime.
b. Maintain the client’s affected hip in an externally rotated position.
c. Instruct the client how to adjust the CPM setting for comfort.
d. Store the CPM machine under the client’s bed when not in use.
13. A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?
a. Radial vein of the inner arm.
b. Great saphenous vein of the leg.
c. Dorsal plexus vein of the foot.
d. Basilic vein of the hand.
14. A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
a. Obesity
b. Acromegaly
c. Estrogen replacement therapy.
d. Sedentary lifestyle.
15. A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
a. Encourage oral fluids.
b. Apply topical calamine lotion
c. Administer acetaminophen as an antipyretic.
d. Initiate transmission-based precautions.
16. A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first?
a. Obtain a prescription for the client to receive an enzyme product.
b. Aspirate the client’s tube.
c. Flush the client’s tube with 30 ml of water.
d. Change the position of the client.
17. A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include?
a. Limit intake of fluids to 1,000 ml daily
b. Take a laxative if no stool has passed after 12 hr.
c. Empty the appliance when it is one-third to one-half full.
d. Change the entire pouch system every 1 to 2 days.
18. A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?
a. Platelets 268,000/mm3
b. Calcium 9,2 mg/dL
c. WBC 5,200/mm3
d. Sodium 148mEq/L
19. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
a. Evaluate dietary intake for a client who has anorexia.
b. Measure the vital signs of a client who just returned from the PACU.
c. Arrange the lunch tray for a client who has a hip fracture.
d. Assess I&O for a client who is receiving dialysis.
20. A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
a. Instruct the client to void.
b. Position the client on their left side.
c. Insert an IV catheter.
d. Prepare the client for moderate (Conscious) sedation.
21. A nurse has received change-of-shift report on for assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
a. A client who is receiving verapamil and has a continuous infusion of total parenteral nutrition (TPN
b. A client who is taking phenytoin and is requesting a milkshake.
c. A client who is receiving a diet high in potassium-rich foods and furosemide by mouth.
d. A client who is receiving an MAOI and is requesting a cheeseburger for dinner.
22. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
a. Perform ADLs for the client to promote rest.
b. Allow for frequent rest periods throughout the day.
c. Use heat to reduce joint inflammation.
d. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain.
23. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reportsbladder spasms, and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?
a. Increase tension on the urinary catheter.
b. Irrigate the catheter with 0.9% sodium chloride irrigation.
c. Assist the client to ambulate.
d. Remove the urinary catheter immediately.
24. A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
a. Weight gain.
b. Decrease in anteroposterior diameter of the chest.
c. HCO3 24 mEq/L.
d. pH 7.31
25. A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the followingmanifestations of ovarian cancer should the nurse include in the teaching?
a. Diarrhea.
b. Urinary retention.
c. Purulent discharge.
d. Abdominal bloating
26. A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent thetransmission of the disease?
a. Initiate contact precautions for the client upon admission.
b. Restrict visitors from entering the client's room during hospitalization.
c. Wear a surgical mask while providing care for the client.
d. Have the client wear a surgical mask while being transported outside the room.
27. A nurse is caring for a group of clients. Which of the following clients should the nurse attend to _first?
a. An older adult client who is anxious and attempting to pull out an IV line.
b. A middle adult client who is reporting nausea after receiving pain medication.
c. An older adult client who has kidney failure and returned from dialysis 4 hr ago.
d. A middle adult client who has a terminal illness and is requesting a visit from the chaplain
28. An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situationsshould the nurse intervene?
A. The LPN and AP lower the side rails before lifting the client up in bed.
B. Prior to lifting the client, the LPN and AP raise the bed to waist level.
C. The LPN and the AP grasp the client under his arms to lift him up in bed.
D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.
29. A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?
a. Hold the insulin pen device perpendicular to the client's skin to inject the medication.
b. Shake the insulin pen device prior to injecting the medication.
c. Withdraw the insulin from the pen device into an insulin syringe.
d. Hold the pen device in place for 3 seconds after injecting the insulin.
30. A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?
a. Assess the client's IV site every 8 hr.
b. Check the client's WBC count every 48 hr.
c. Monitor the client's mouth every 8 hr.
d. Change the client's IV tubing every 48 hr.
31. A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understandingof the teaching?
a. "I can designate my partner as my health care surrogate."
b. "I am only 40 years old, so I don't need to worry about this yet."
c. "I will need a lawyer's help to draw up the documents."
D. "I understand that my family can alter my advance directives if I become incapacitated."
32. A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should thenurse expect to administer?
a. Nalbuphine
b. Terbutaline
c. Oxytocin
d. Magnesium sulfate
33. A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nursemanager demonstrates a democratic leadership style?
a. Avoids initiating change
b. Seeks input from the other nurses
c. Makes decisions quickly
d. Limits the amount of feedback to the sta_
34. A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign tothe member of the group functioning as the orienteer?
a. Measuring the group's work against the assigned objectives
b. Noting the progress of the group toward assigned goals
c. Sharing experiences as an authority
d. Offering new and fresh ideas on an issue
35. A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? (Click on the"Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
a. Initiate droplet isolation precautions.
b. Keep the child on NPO status for 12
c. Maintain the child on bed rest for 24 hr.
d. Administer high-dose antibiotic therapy.
36. A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat lossby conduction?
a. Dry the newborn immediately after birth.
b. Maintain an ambient room temperature of 24° C (75.2° F).
c. Use a protective cover on the scale when weighing the infant.
d. Place the newborn's bassinet away from outside windows.
37. A nurse is caring for a client who had abdominal surgery 24 hr. ago. Which of the following actions is the nurse's priority?
a. Assess fluid intake every 24 hr.
b. Ambulate three times a day.
c. Assist with deep breathing and coughing.
d. Monitor the incision site for findings of infection.
38. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectivelyusing sublimation as a defense mechanism?
a. A client who transfers their anger about their job onto their family and then apologizes
b. A client who misses provider appointments because they say they are too busy
c. A client who channels their energy into a new hobby following the loss of their job
d. A client whose partner died 4 years ago sets a place for him at dinner each night
39. A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actionsshould the nurse take?
a. Insert air in the tube and listen for gurgling sounds in the epigastric area.
b. Aspirate contents from the tube and verify the pH level.
c. Review the medical record for previous x-ray verification of placement.
d. Auscultate the lungs for adventitious breath sounds.
40. An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
a. A client who is at 33 weeks of gestation and has severe gestational hypertension
b. A client who is at 16 weeks of gestation and has a hydatidiform mole
c. A client who is at 28 weeks of gestation and is experiencing vaginal bleeding
d. A client who is at 36 weeks of gestation and has a positive group B streptococcal culture
41. A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?
Check the functioning of oxygen equipment once each week.
Wear clothing made with cotton fabrics while oxygen is in use
Apply petroleum-based lubricant to the nares as needed.
Store full oxygen tanks on their side.
42. A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
Adjust the crutches for comfort as needed.
Use a three-point gait
Wear leather-soled shoes.
Advance the affected leg first when walking upstairs.
43. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
The last time the provider evaluated the client
The client's most recent ventilator settings
The time of the client's last dose of pain medication
The frequency in which the client presses the call button
44.A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?
Heart rate 122/min
Irritability when being held
Hypoactive bowel sounds
Urine specific gravity 1.018
45. A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?
Decreased blood pressure
Decreased hallucinations
Decreased cholesterol
Decreased esophageal reflux
46. A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?
"Expect to have blurred vision while taking this medication."
"Notify your provider if you experience increased thirst."
"You should take this medication on an empty stomach."
"You might be unable to have an orgasm while taking this medication."
47. A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
Place the client in the lithotomy position.
Elicit a vagal response by performing gentle rectal stimulation.
Administer oral bisacodyl 30 min prior to the procedure.
Insert a lubricated gloved finger and advance along the rectal wall
48. A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
Perform gastrostomy feedings through a client's established gastrostomy tube
Administer a glycerin suppository to a client who is constipated.
Provide instructions about client care to a family member over the telephone.
Teach a client how to measure their own blood pressure.
49. A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?
Delegate non-nursing tasks to ancillary staff.
Stock client rooms with extra supplies.
Assign dedicated equipment to each client's room.
Change continuous IV infusion tubing every 24 hr.
50. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
The client is taking numerous deep, measured breaths.
The client is calmly telling their partner that "the staff here is so controlling."
The client is sitting with their head in their hands and appears to be crying
The client is pacing around the chair in which their partner is sitting.
51. A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?
"Perhaps you think the ECT is dangerous, but I've seen it have good results."
"You have the right to change your mind about this procedure at any time."
"Everyone gets a little nervous about this procedure as the time for it approaches."
"Your doctor wouldn't have suggested ECT if they didn't think it would help you."
52. A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
Agency for Healthcare Research and Quality.
National Institutes of Health
Department of Agriculture
World Health Organization
53. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
Heart rate 136/min
Nasal flaring
Transient strabismus
Overlapping of sutures
54. A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
Evaluate the changes the partner requests.
Review the client's plan of care.
Analyze other reports of poor care to look for trends.
Ask the partner to list specific concerns.
55. A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
"You will be standing with your feet 1 foot apart."
"You will place and hold your hands on your hips."
"I will be standing across the room from you to evaluate your sense of balance."
"I will be checking you once with your eyes open and once with them closed."
56. A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I will decrease my intake of high-fiber foods."
"I will apply hydrocortisone cream if I develop a rash on my face."
"I will sleep flat on my back if I develop back pain."
"I will wear a supportive bra overnight."
57. A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
Weight loss
Jaundice
Bradycardia
Polyuria
58. A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? (Select all that apply.)
"I will breastfeed my baby on a schedule of every 4 hours."
"I will bathe my baby daily."
"I will place my baby on her stomach for sleeping."
"I will cover my baby's body when I wash her hair."
"I will use the bulb syringe first in her mouth and then in her nose."
59. A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?
Mood
Speech
Ideas of self-harm
Memory loss
60. A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
13 gtt/min
61. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
Irritability
Increased Urination
Vomiting
Facial flushing
62.A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?
Agitation
Short-term memory loss
Post-treatment seizures
Incontinence of the bowel and bladder
63.A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this con conflict?
"I would like to talk to you about the unit policies regarding break time."
"If you continue to take a long lunch break, I will have to report this to the nurse manager."
"Have you thought about how your extended lunch breaks affect the other members of our team?"
"Did you inform the other members of your team about when you left and returned from break?"
64. A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?
Hgb 15 g/dL
Specific gravity 1.052
Urine osmolality 300 mOsm/kg
Hct 44%
65.A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding?
Creatinine 1.1 mg/dL
Albumin 2.8 g/dL
Triglycerides 100 mg/dL
Alkaline phosphatase 118 units/L
66.A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?
"I have experienced physical discomfort when intimate with my partner since my diagnosis."
"I wish other women would stop socializing with my partner."
I told my doctor that I would like to start a support group for other women who are sick in my community
I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness."
67.A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)
Broccoli
Yogurt
Pepperoni pizza
Cream cheese
Bologna sandwich
68.A nurse is assessing a client for compartment syndrome. Which of the followingfindings should the nurse expect?
Fever
Shortened femoral neck
Edema
Dark brown urine
69.A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?
Instruct the client about the importance of regular medical appointments.
Encourage the client to participate in daily exercise.
Explain proper foot care techniques to the client.
Ensure that the client understands the medication regimen.
70.A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
Halos around lights
Floating dark spots
Pain in the affected eye
Blurred vision
71. A nurse on a medical-surgical unit is assessing a client how has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
Difficulty performing ADLs
Inability to swallow clear liquids
Elevated blood glucose levels
Unsteady gait when ambulating
72. A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?
Sudden drop in heart rate
Rapid decrease in blood pressure
Client reports a feeling of abdominal fullness
Client reports pain as 8 on a scale of 0 to 10
73. A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, “I don’t want my brother to die, but what if I need this kidney one day? Which of the following responses should the nurse make?
“I understand your hesitation, but I’m very proud of you for making the right decision”
Organ donation from for a first-degree relative is your brother’s best chance of survival”
“You’re afraid that your other kidney will fail at some point after the organ donation”
“I know this process won’t be easy, but you should focus on saving your brother’s life”
74. A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum
Bradycardia
Flushed, dry skin
Wheezing
75. A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client’s medical record?
Completion of the incident report
Time the medication was given
Reason for the medication error
Notification of the pharmacist
76. A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?
Check the client’s temperature
Prepare to administer acetylcysteine to the client
Place the client in the Trendelenburg position
Check the client’s oxygen saturation level
77. A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has a scald burns to both hands and wrist. The nurse suspects physical abuse. Which of the following actions should the nurse take?
Discuss the suspicion of physical abuse with the provider.
Confront the parents with the suspicion of physical abuse.
Ask the hospital security to detain and question the parents.
Contact Child Protective Services.
78. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spots that corresponds to your answer.)
Aparece la imagen de un bebe y tiene marcada 3 partes del cuerpo
A (ojos)
B (corazón)
C (abdomen)
79. A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, “My family does not care whether I live or die.” Which of the following responses should the nurse make?
“I’m sure your family does not want you to die”
“Why would you believe such things?”
“How does this make you feel?”
“You should talk to your family about your feelings”
80. A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
“You will give the medication every 4 hours.”
“Shake the medication bottle well before each dose is given.”
“Store the medication in the refrigerator.”
“Report diarrhea to the provider immediately.”
“Discard the unused portion of medication after 21 days.”
81. A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loves ones. Which of the following actions should the nurse take?
Contact the facility chaplain to visit with the client
Explain the process of leaving the facility against medical advice. Therefore, the nurse should notify the provider of the client’s wishes.
Make a referral for social services
Encourage the client to continue with inpatient care
82. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?
Drainage system located above the client’s chest level.
Continuous bubbling in the water -seal chamber
Occlusive dressing on the insertion site
Drainage of 125 mL/hr
83. A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client’s family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?
Facilitate an interdisciplinary conference at the new facility for the family
Refer the client and family to social worker for assistance and follow -up meeting.
Reassure the client’s family that the same provider care at the new facility.
Tell the family that the rehabilitation facility has an excellent client care record
84. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?
Diarrhea
Frequent urination
Excessive salivation
Blurred vision
85. A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statement by one of staff nurses indicates an understanding of isolation precaution?
Droplet precautions should be initiated for a client who tests positive for measles.
A client who requires airborne precautions should be placed in a negative pressure airflow room
Airborne precautions should be initiated for a client who has clostridium difficile
A client who is immunocompromised should be placed in negative – pressure airflow room
86. A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
Check the client’s blood type and crossmatch against the provider’s orders
Ask the client to state their blood type prior to beginning blood administration
Compare information on the blood product to the informed consent form
Verify the client and blood product information with another licensed nurse
87. A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self – inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?
Borderline
Antisocial
Historic
Paranoid
88. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?
Obtain capillary blood glucose level every 2 hr.
Check the neurovascular status of the client’s lower extremities every hour
Apply a cold pack to the client’s ankle for 30 min every hour.
Maintain the affected ankle elevated and immobilized
89. A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?
Tinnitus
Cough
Polyuria
Blurred vision
90. A nurse is reviewing the ABG values of a client. The client has a ph of 7.2, PaCO2 of 60 mm Hg and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalance?
Respiratory alkalosis
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
91. A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse of this medication?
Have you experienced muscle stiffness?
Have you had any stomach pain or bloody stools?
Have you experienced a dry cough?
Have you noticed an increase in urine output?
92. A nurse on a pediatric unit has received change – of – shift report for four children. Which of the following children should the nurse assess first?
A 6 – month- old infant has croup and an O2 saturation of 92 % on room air
A 15- year- old adolescent who is 2 hr postoperative following an open reduction and internal fixation. Therefore, the nurse should assess another client first.
A 3-year- old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr.
A 10 – year- old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain.
93. A nurse on an inpatient unit is caring for a client who has schizophrenia, and recently started taking risperidone. Which of the following actions should the nurse take?
Implement fall precautions for the client
Monitor the client’s thyroid function
Place the client on a fluid restriction
Discontinue the medication if hallucination
94. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify the which of the following physiological changes is the cause for the client’s visual loss?
An increase in the intraocular pressure, causing mild headaches and foggy vision
Deterioration of the macula
Increased opacity of lens
Vitreous hemorrhage
95. A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?
Constipation
Urinary urgency
Cervical Laceration
Retained placenta
96. A nurse is updating the plan of care for a client who is 48 hr. postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
Determine the client’s reading skills
Instruct the client on the technique for esophageal speech
Provide the client with an alphabet board
Show the client to use an artificial larynx
97. A nurse is caring for school -age child has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?
Hematocrit 45%
Urine specific gravity 1.035
Serum sodium 138 mEq/L
BUN 19 mg/dl
98. A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
Instruct a staff member to maintain a log of emergency care provider
Apply cervical spine collars to children who have suspected neck trauma
Notify guardians of the emergency and injuries to their children
Survey the scene for potential hazards to staff and children
99. A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client’s family to obtain consent. Which of the following actions should the nurse take?
Contact the facility’s ethics committee
Obtain consent from the client’s employer
Limit care to comfort measures
Proceed with provision of medical care
100. A nurse is caring for a school- age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?
Chest x- ray
Serum liver enzyme levels
ABGs
Urine culture and sensitivity
101. A nurse manager is preparing to teach a group of newly licensed about effective time management. Which of the following steps of the time management process should the nurse manager included as the priority?
Organizing the work environment
Delegating assigned tasks appropriately
Making a list of activities to complete
Rewarding yourself for accomplishing goals
102. A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds, and INR 1.8. Which of the following actions should the nurse take?
Prepare to administer vitamin K1.
Prepare to administer alteplase
Withhold the heparin infusion.
Withhold the next dose of warfarin.
103.A nurse is providing teaching to a school-age child who has asthma about using an albuterol metereddose inhaler. Which of the following instructions should the nurse include?
Clean the mouthpiece with warm water every 2 weeks.
Wait 10 seconds between inhalations.
Take a quick inhalation when pressing the dispenser.
Take the medication 15 min before playing sports
104. A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
"My child doesn't like to sit still for nebulizer treatments."
"I think that my child has been running a fever over the last couple of days."
"My child has only a small amount of mucus after percussion therapy."
"I am concerned about my child's future participation in team sports."
105. A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet.
Restrict visits from young children to 2 hr per day.
Measure the client's temperature once per shift.
Use disposable gloves from a box outside the client's room.
106. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?
Amount of vaginal bleeding
Amount of urinary output
Pain level
Fundal height
107. A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?
Decreased hematocrit
Hypokalemia
Hyponatremia
Increased albumin
108. A nurse is teaching a client who has a new prescription for a total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?
"I will change your IV tubing once every 48 hours."
"Abdominal distention is an expected effect of this therapy."
"I will need to check your gastric residual before administering feedings."
"I will need to measure your weight daily."
109. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using?
Tangentiality
Flight of ideas
Word salad
Perseveration
110. A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?
A client whose family requests hospital-based hospice care
A client who requires transfer to a skilled care facility
A client who qualifies for telehealth for pacemaker diagnostics
A client whose caregiver requests adult day care services
111. A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?
A client forgets to buy their partner a birthday gift after a disagreement
A client who was abused as a child describes the abuse as if it happened to someone else
A client who is shorter than average is verbally assertive with coworkers.
A client states that they did not get a job promotion because the boss did not like them.
112. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?
Wear a surgical mask when providing client care.
Have visitors maintain a distance of 1.8 m (6 feet) from the client.
Restrict fresh owners from the client's room.
Assign the client to a private room with negative air pressure
113. A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
"Limit your fat intake for 72 hours before the test."
"You will need to fast the night before the test."
"We will collect a urine sample the day after testing."
"A blood sample will be collected every 15 minutes during the test."
114. A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
"I will administer aspirin to my child to treat pain or fever."
"I will record an average of three readings from my child's peak expiratory ow meter."
"I will place carpet in my child's bedroom to control allergens."
"I will make sure my child receives a yearly influenza immunization."
115. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?
aPTT
PT
INR
WBC count
116. A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
Weight loss
Wheezing
Blood pressure 146/92 mm Hg
Heart rate 110/min
117. A client is receiving IV units at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Oliguria
Bradycardia
Dyspnea
Poor skin turgor
118. A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?
"It's natural for you to feel this way now, but things will get better with time."
"You seem to be having a difficult time right now."
"Why do you feel like your life isn't worth living?"
"You'd be surprised how many people experience these feelings."
119. A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
A client who has cellulitis and is receiving oral antibiotics every 8 hr
A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex
A mother and their newborn 12 hr post delivery
A client who has lower extremity weakness and is newly admitted for observation
120. A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?
February 1
February 8
February 15February 22
121. A nurse providing teaching about home care to parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?
Use a reward system to modify the child’s behavior.
122. A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood lead level of 3 mcg/dl. Which of the following actions should the nurse take?
Recommend rescreening in1 year
123. A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?
Tell me more about your understanding of the options
124. A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the followings findings is an adverse effect of this medication?
Dry mouth
125. A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?
Support the client’s left arm on a pillow while sitting.
126. A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?
Explore the client reasons for refusing the treatment.
127. A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Inspection, Auscultation, Percussion, palpation
128. A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?
I will not allow anyone to smoke near my baby
129. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
Maintain sterile objects within the line of vision
130. A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following intervention should the nurse plan to take?
a. Initiate continuous cardiac monitoring
131. A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?
The client reports a decrease in episodes of nausea
The client reports a decrease in breast tenderness.
The client reports a decrease in headaches.
The client reports a decrease in urinary frequency.
132. A nurse is caring for a client who has a deep-vein thrombosis. Which of the following actions should the nurse take?
Teach the client to massage the affected extremity.
Instruct the client to elevate the affected extremity when sitting
Assess pulses proximal to the affected area.
Apply a cold compress to the affected extremity.
133. A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?
Withhold pain medications for 24 hr after the old patch is removed.
Ask another nurse to witness the disposal of the new patch
Seal the patches in a plastic bag and place in the client's trash basket.
Stick the two patches to each other and place them in the sharps bin.
134. A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?
Paradoxical chest movement
Subcutaneous emphysema
Acute confusion
Distended neck veins
135. A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?
"Your body temperature will drop approximately 1 degree 1 week after ovulation."
"You should take your body temperature each evening prior to going to sleep."
"Your body temperature might decrease slightly just prior to ovulation."
"Your body temperature is at its highest during menstruation."
136. A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?
Form a committee of staff members to investigate current staffing issues
Provide support to staff members who are resistant to staffing changes.
Schedule a staff meeting to present the different options to staff members.
Give the staff members advance written notice of staffing changes.
137. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?
Select a 1-inch needle.
Use a 45º angle when inserting the needle.
Use the ventrogluteal site
Pinch the skin up during injection.
138. A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?
"We can expect the hospice nurse to provide support for us after our mother's death."
"A hospice nurse will come to the house each time our mother needs pain medication."
"Now that my mother is receiving hospice services, we will not be able to get respite care."
"Hospice care focuses on arranging treatment that will prolong our mother's life."
139. A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
Hypotension
Report of tinnitus
Report of chest pain
Ecchymosis
140. A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
Hypoxemia
Tension pneumothorax
Malignant hypertension
Atelectasis
141. A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
Autonomy
Nonmaleficence
Justice
Fidelity
142.A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?
Documents client tasks upon completion
Starts a task then determines what supplies are needed
Completes a client assessment while infusing an IV antibiotic over 30 min
Returns to the nurses' station after completing several tasks in the same location
143.A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?
Advocacy is a leadership role that helps others to self-actualize.
Subordinates are advocates for the nurse manager.
Advocacy encourages clients to rely on health care staff for decision-making.
Nurse managers should distrust people who advocate against inappropriate professional practices.
144.A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?
Droplet
Airborne
Contact
Protective environment
145.A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first?
A client who is postoperative with abdominal distention and no bowel sounds
A client who has diabetes mellitus and a blood glucose level of 105 mg/dL
A client who has heart failure and 2+ pitting edema
A client who is receiving maintenance IV fluids and needs a new IV catheter
146.During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
Keep the client's television on with the volume low.
Insert an indwelling urinary catheter to minimize interaction with the client.
Consult the provider regarding administering a mild sedative on a schedule.
Move the client to a room near the nurses' station
147. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect?
11 seconds
22 seconds
30 seconds
45 seconds
148.A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?
Encourage the client to take a cool sponge bath each morning.
Administer opioid analgesia.
Increase the client's dietary iron intake.
Restrict the client's intake of foods high in purines.
149.A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?
Strict adherence to routines
Difficulty paying attention to tasks
Disobedience to authority figures
Excessive anxiety when separated from parents
150. A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?
Flex the client's neck forward.
Group several nursing activities to be completed at one time.
Limit suctioning the client's airway to 30 seconds at a time.
Place the client in a quiet environment
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