NR 340 CRITICAL CARE NURSING NR 340 HESI FINAL EXAM All Correct Answers(GRADED A+)

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NR 340 HESI FINAL EXAM NR 340 CRITICAL CARE NURSING Answers are highlighted in purple color (GRADED A+) Multiple Choice Identify the letter of the choice that best completes the statement or a... nswers the question. 1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding? a. Palpate for the presence of femoral pulses bilaterally. b. Assess for the presence of a positive Homan's sign. c. OBSERVE THE APPEARANCE OF THE SKIN ON THE CLIENT'S LEGS. d. Watch the client's posture and balance during ambulation. 2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant receive? a. 9 mg. b. 18 mg. c. 27 mg. d. 36 mg. 3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should the nurse implement? a. Continue the magnesium sulfate infusion as prescribed. b. Decrease the magnesium sulfate infusion by one-half. c. STOP THE MAGNESIUM SULFATE INFUSION IMMEDIATELY. d. Administer calcium gluconate immediately. 4. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective? a. THE CLIENT’S EXPREMITIES ARE PARALYZED. b. The peripheral nerve stimulator causes twitching. c. The client clinches fist upon command. d. The client’s Glagow Coma Scale score is 14. 5. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report? a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due to dehydration. b. LOOK FOR AN INCREASE IN TODAY'S LDH COMPARED TO THE PREVIOUS ONE TO ASSESS FOR POSSIBLE LIVER DAMAGE. c. Expect to find an increase in today's APTT as compared to last quarter's due to bleeding. d. Determine if there is a decrease in serum potassium due to renal compromise. 6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement? a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath. b. Administer the aspirin with at least two ounces of water or juice. c. NOTIFY THE HEALTHCARE PROVIDER IF THE CHILD COMPLAINS OF RINGING IN THE EARS. d. Advise the parents to question the child about seeing yellow halos around objects. 7. Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome? a. Husky voice and complaints of hoarseness. b. Warm, soft, moist, salmon-colored skin. c. Visible swelling of the neck, with no pain. d. CENTRAL-TYPE OBESITY, WITH THIN EXTREMITIES. 8. A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client a. admitted yesterday with diabetec ketoacidosis whose blood glucose level is now 195 mg/dl. b. with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch. c. post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube. d. WITH A PNEUMOTHORAX SECONDARY TO A GUNSHOT WOUND WITH A CURRENT PULSE OXIMETER READING OF 90%. 9. An outcome for treatment of peripheral vascular disease is, "The client will have decreased venous congestion." What client behavior would indicate to the nurse that this outcome has been met? a. AVOIDS PROLONGED SITTING OR STANDING. b. Avoids trauma and irritation to skin. c. Wears protective shoes. d. Quits smoking. 10. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? a. Pedal pulses. b. Breath sounds. c. Gag reflex. d. VITAL SIGNS. 11. The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals? a. Prevents indigestion associated with ingestion of spicy foods. b. BINDS WITH PHOSPHORUS IN FOODS AND PREVENTS ABSORPTION. c. Promotes stomach emptying and prevents gastric reflux. d. Buffers hydrochloric acid and prevents gastric erosion. 12. The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearance" for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis? a. Pain when coughing. b. DIMINISHED COUGH EFFORT. c. Thick dry secretions. d. Excessive inflammation. 13. Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bowel sounds and firm, distended abdomen. Which prescription for the client should the nurse question? a. CONTINOUS TUBE FEEDING AT 65 ML/HR VIA GASTROSTOMY. b. Total parenteral nutrition to be infused at 125 ml/hour. c. Nasogastric tube connected to low intermittent suction. d. Metoclopramide (Reglan) intermittent piggyback. 14. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate? a. Bounding erratic pulse. b. Regularly irregular pulse. c. Thready irregular pulse. d. NO PALPABLE PULSE. 15. In assessing a 70-year-old female client with Alzheimer's disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care? a. Scrub the lesions with warm soapy water. b. Encourage the client to drink orange juice for added vitamin C. c. Notify the healthcare provider of the need for oral antibiotics. d. ENSURE THAT THE CLIENT GETS ADEQUATE B VITAMINS IN FOODS OR SUPPLEMENTS. 16. A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response? a. "You are lucky to be alive. Be grateful no one was killed." b. "I understand your car was not seriously damaged." c. "You are upset that this incident has brought you here." d. "Have you ever been in the emergency department before?" 17. An 85-year-old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation? a. This is sexual harassment and needs to be reported to the administration immediately. b. The UAP needs to be reassigned to another group of residents, preferably females only. c. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need. d. The resident needs to know the rules concerning unwanted touching of the staff and the consequences. 18. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? a. Repair should be done by one month to prevent bladder infections. b. Repairs typically should be done before the child is potty-trained. c. Delaying the repair until school age reduces castration fears. d. To form a proper urethra repair, it should be done after sexual maturity. 19. In evaluating teaching of a client about wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure? a. “I must record any symptoms occurring with my activity.” b. “I am not looking forward to staying in bed for 24 hours.” c. “I really am dreading the frequent blood drawing.” d. “I know that I shouldn’t get close to my microwave oven.” 20. A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report? a. Refuses to eat her favorite meals at home. b. Drinks more soft drinks than previously. c. Voids only one or two times per day. d. Gained 10 pounds within one month. 21. The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm3. What intervention should the nurse implement? a. Increase Client A's oxygen to 4 liters per minute via nasal cannula. b. Determine if Client B has two units of packed cells available in the blood bank. c. Ask the dietician to add a banana to Client C's breakfast tray. d. Inform Client D that surgery is likely to be delayed until the infection is treated. 22. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has "little reason to live." She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement? a. Encourage the client to remove the gun from her possession. b. Notify the client's healthcare provider of the availability of the weapon. c. Contact a person of the client's choosing to remove the weapon from the home. d. Call the local police department and have the weapon removed from the home. 23. It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation? a. A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate. b. A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells. c. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside. d. An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale. 24. A nurse is completing the health history for a 25-year-old male client who reports that he is allergic to penicillin. Which question should the nurse ask after receiving this information? a. "Are you allergic to any other medications?" b. "How often have you taken penicillin in the past?" c. "Is anyone else in your family allergic to penicillin?" d. "What happens to you when you take penicillin?" 25. A 10-year-old child with meningitis is suspected of having diabetes insipidus. In evaluating the child's laboratory values, which finding is indicative of diabetes insipidus? a. Decreased urine specific gravity. b. Elevated urine glucose. c. Decreased serum potassium. d. Increased serum sodium. 26. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? a. Administer sargramostim (Leukine, Prokine). b. Infuse PRBC and platelet transfusions. c. Give parental prophylactic antibiotics. d. Maintain a protective isolation environment. 27. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority? a. Apply a hypothermia unit to stabilize core temperature. b. Increase the client's IV fluid rate to 200 ml/hr. c. Call the hospital chaplain to counsel the family. d. Draw blood cultures x 3 to detect infection. 28. A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first? a. Check the blood glucose level. b. Draw blood for a Hemoglobin A1C. c. Assess urine for ketone levels. d. Provide the client with a protein snack. 29. A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? a. Administer oxygen via face mask. c. Notify the operating room team. b. Place the client in Trendelenburg. c. Administer a fluid bolus of 500 ml. 30. The nurse is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention? a. Weigh the child daily. b. Observe the lower extremities for pitting edema. c. Measure the child's abdominal girth weekly. d. Weigh the child's wet diapers. 31. The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother? a. The child can be around other children but should wear a mask at all times. b. The child will no longer be contagious, no need to take any further precautions. c. Make sure there are no children under the age of 6 months around the infected child. d. Do not expose other children. RSV is very contagious even without direct oral contact. 32. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first? a. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. b. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours. c. Pantoprazole (Protonix) 40 mg PO daily d. Enoxaparin (Lovenox) 40 mg subq q24 hours. 33. Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? a. Administer an antiemetic before starting the chemotherapy. b. Instruct the client to drink plenty of fluids during the treatment. c. Keep the head of the bed elevated until the treatment is completed. d. Monitor the client's intravenous site hourly during the treatment. 34. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented? a. Obtain a urine specimen for culture and sensitivity. b. Encourage the client to schedule a digital rectal exam. c. Advise the client to maintain a voiding diary for one week. d. Instruct the client in effective techniques to cleanse the glans penis. 35. The nurse is performing an admission physical assessment of a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider? a. Heel stick glucose of 65 mg/dl. b. Head circumference of 35 cm (14 inches). c. Widened, tense, bulging fontanel. d. High-pitched shrill cry. 36. Which client's laboratory value requires immediate intervention by a nurse? a. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams. b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday. c. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value. d. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday. 37. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding? a. 4+ pitting edema of both lower extremities. b. A Braden risk assessment scale rating score of ten. c. Warm, dry skin with a fever of 100° F. d. Hypoactive bowel sounds with infrequent bowel movements. 38. The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, "The pills don't seem to be working. They are not helping the pain at all." Which factor should influence the nurse's response? a. Noncompliance is probably affecting optimum medication effectiveness. b. Drug dosage is inadequate and needs to be increased to four times a day. c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream. d. NSAID response is variable and another NSAID may be more effective. 39. A nurse is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information? a. Disease registry. b. Department of Health. c. Bureau of Vital Statistics. d. Census data. 40. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client? a. Glasgow coma scale. b. Pulses, paresthesia, paralysis distal to the right knee. c. Pulses, paresthesia, paralysis proximal to the right knee. d. Optic nerve using an ophthalmoscope. 41. A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. Encourage him to initiate daily rituals. b. Reinforce the reality of his financial situation. c. Direct him to drink a glass of red wine at bedtime. d. Teach him to limit sugar and caffeine intake. 42. What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum? a. Soft, spongy fundus. b. Saturating two perineal pads per hour. c. Pulse rate of 56 BPM. d. Unilateral lower leg pain. 43. The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? a. "It will help you function better in the community." b. "The medication will help you think more clearly." c. "You will be able to cope with your symptoms." d. "It will improve your grooming and hygiene." 44. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse? a. Is unable to feel sensation in the arms and hands. b. Has flaccid upper and lower extremities. c. Blood pressure is 110/70 and the apical pulse is 68. d. Respirations are shallow, labored, and 14 breaths/minute. 45. A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant? a. Ampicillin (Omnipen) 25 mg/kg slow IV push. b. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV. c. Digoxin (Lanoxin) 20 micrograms/kg IV. d. Beractant (Survanta) 100 mg/kg per endotracheal tube. 46. Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? a. An adult who had a colon resection yesterday and has an IV. b. An older adult who has a fever of unknown origin. c. A woman who had an acute brain attack (stroke, CVA) 6 hours ago. d. A teenager with a femoral fracture who is in traction. 47. A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures? a. Chorionic villi sampling under ultrasound. b. Amniocentesis and fetal monitoring. c. Ultrasonography and nonstress test. d. Oxytocin challenge test and fetal heart rates. 48. A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? a. Tell him he can have a day pass if he calms down. b. Put the client's behavior on extinction. c. Decrease the volume on the television set. d. Instruct the client to sit down and be quiet. 49. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the most likely reason for the nurse's behavior? a. The nurse is stating disapproval of the statement. b. The nurse is respecting the client's loss. c. Silence is reflecting the client's sadness. d. Silence allows the client to reflect on what was said. 50. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the charge nurse implement first? a. Notify the healthcare provider of the assessment findings. b. Determine if the client received anesthesia during delivery. c. Assign a practical nurse (PN) to reassess the client's vital signs. d. Obtain a STAT hemoglobin and hematocrit. 51. In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should recognize that which intervention is essential? a. Keep the arm and shoulder of the affected side immobile at all times. b. Ensure that there is no fluctuation in the water-seal chamber. c. Encourage the client to breathe deeply and cough at frequent intervals. d. Maintain the Pleuravac® slightly above the chest level. 52. Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions? a. Assessing pedal pulses frequently and monitoring the nasogastric drainage. b. Maintaining strict bedrest for 72 hours and assessing radial pulses. c. Monitoring an infusion of IV heparin and checking the PTT level daily. d. Assessing the right flank dressing and monitoring the suprapubic Foley catheter. 53. A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? a. Exhale forcefully into the tubing for 3 to 5 seconds. b. Inspire deeply and slowly over 3 to 5 seconds. c. Breathe into the spirometer using normal breath volumes. d. Perform IS breathing exercises every 6 hours. 54. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse? a. The nurse is guilty of negligence and will be sued. b. The client would not be able to prove malpractice in court. c. The nurse is protected by the Good Samaritan Act. d. The healthcare provider should have given the morphine sulfate dose. 55. A client with which problem requires the most immediate intervention by the nurse? a. Finger paresthesias related to carpal tunnel syndrome. b. Increasing sharp pain related to compartment syndrome. c. Increasing burning pain related to a Morton's neuroma. d. Increasing sharp pain related to plantar fascitis. 56. The charge nurse should intervene when what behavior is observed? a. Two staff members are overheard talking about a cure for AIDS outside a client's room. b. A hospital transporter is reading a client's history and physical while waiting for an elevator. c. A UAP tells a client, "It's hard to quit drinking but Alcoholic Anonymous helped me." d. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge. 57. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy? a. Client denies allergies to contrast media. b. Skin prep to insertion site completed. c. On-call sedation administered. d. Oxygen at 2 L/minute per nasal cannula. 58. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool. b. Splint affected joints during activity. c. Perform passive range of motion exercises twice daily. d. Begin a training program lifting weights and running. 59. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client? a. Delirium b. Presbyopia c. Presbycusis d. Cerebral dysfunction. 60. A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective? a. Reports reduced nasal discharge. b. Denies having coughing spells. c. Able to sleep through the night. d. Expectorating bronchial secretions. 61. The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first? a. The mother who took her children from school because aliens were after them. b. The young man who has a history of substance abuse and has no telephone. c. The newly diagnosed client who needs to be evaluated for medication compliance. d. The young woman who believes she is to blame for her recent miscarriage. 62. The nurse is caring for a client whose urine drug screen is positive for cocaine. What behavior is this client likely to exhibit during cocaine withdrawal? a. Intense cravings. b. Increased energy. c. Talkativeness. d. Euphoria 63. The nurse enters the room of a client with a history of seizure activity and observes that the unlicensed assistive personnel (UAP) is securing several pillows against the side rails to protect the client. What action should the nurse implement? a. Ensure that the UAP has placed the pillows effectively to protect the client. b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. c. Assume responsibility for placing the pillows while the UAP completes another task. d. Ask the UAP to use some of the pillows to prop the client in a side-lying position. 64. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? a. Initiate normal saline IV at 50 ml/hr. b. Administer a loading dose of penicillin IM. c. Obtain a culture of any sputum or wound drainage. d. Administer the initial dose of folic acid PO. 65. A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instruction? a. Keep the left leg in a dependent position. b. Apply heat to the left leg cast. c. Do not attempt to scratch the skin under the cast. d. Apply a cold pack to any "hot spots" on the cast. 66. A client has 2nd degree electrical burns on both upper extremities. The nurse is preparing to administer the first application of the topical antimicrobial agent mafenide acetate (Sulfamylon) to the burned area. Which intervention should the nurse implement first? a. Premedicate the client prior to applying the medication. b. Use sterile gloves when applying this medication. c. Cleanse the burned area with sterile normal saline. d. Assess the client's most recent arterial blood gas test results. 67. The community health nurse must provide a primary prevention program in the community. Which type of program addresses this need? a. Provide a nurse-practitioner to prescribe medications for clients with heart disease. b. Arrange cardiac-prudent diets to be delivered to individuals using Meals on Wheels. c. Incorporate an exercise program at a local Hispanic community center. d. Conduct a weekly blood pressure screening at the Hispanic senior citizen center. 68. The nurse is conducting assessments at the beginning of the shift. Which client is most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago? a. A young female with increased urinary output following administration of IV furosemide (Lasix). b. A middle-aged male receiving prazosin hydrochloride (Minipress). c. An elderly male who received two units of packed red blood cells (RBCs). d. An adolescent who is receiving azathioprine (Imuran) following a cardiac transplant. 69. A client is hemiplegic following a cerebrovascular accident. To prevent this client from experiencing a painful shoulder, what intervention should the nurse include in the plan of care? a. Exercise the affected shoulder by using it when assisting the client out of bed. b. Position the affected arm on pillows while the client is seated in a chair. c. Keep the client's affected arm elevated above the level of the heart. d. Avoid range of motion exercises on the affected shoulder until pain in the shoulder has passed. 70. The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client's medication administration record (MAR). Which action should the nurse take to prevent a medication error from occurring? a. Compare the medication label with the medication administration record (MAR). b. Check the client's identification bracelet prior to administering the medication. c. Compare the medication administration record (MAR) to the prescription. d. Verify the room number on the medication administration record (MAR). 71. While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement? a. Permit privacy for the mother and infant to bond. b. Assist the mother to elicit a rooting reflex in the infant. c. Place a small amount of glucose water on the breast. d. Evaluate the infant's sucking reflex then give the infant to the mother. 72. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? a. "Milk does contain tryptophan, which helps many people fall asleep." b. "Drinking milk before bedtime can increase your symptoms at night." c. "A warm drink, such as hot tea or cocoa should be substituted for the milk." d. "Taking an antispasmodic medication with the milk will reduce the symptoms." 73. A client diagnosed with Type 1 diabetes is NPO for a diagnostic test. The nurse is preparing to administer 24 units of 70/30 insulin. Which intervention should the nurse implement first? a. Administer the insulin subcutaneously in the client's abdomen. b. Administer the insulin when the client returns from the test. c. Contact the healthcare provider to adjust the insulin dose. d. Call the department and request that this client's test be done first. 74. The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid? a. Toasted white bread with butter. b. Whole grain cereal and milk. c. Hard-boiled egg and juice. d. Vanilla milkshake with protein supplement. 75. A 36-year-old client is admitted to the ICU following a six-hour surgery to repair a fractured pelvis, and the estimated intraoperative blood loss (EBL) was 3,000 ml. Current client data include: BP 85/70, heart rate 140 beats/minute, urine output 10 ml/hr, PAWP 2, RAP -3, Hct 20%, Hgb 7 g/dl. What action should the nurse take at this time? a. Administer propranolol (Inderal) to decrease the heart rate. b. Infuse blood and IV fluids to correct the hypovolemia. c. Start a dopamine (Intropin) infusion to raise the BP. d. Draw serum blood cultures to check for infection. 76. An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take? a. Notify the unit manager that an emergency court order is needed to allow the surgery. b. Continue to prepare the client for the surgery without a signed informed consent. c. Ask the woman's friend to sign the informed consent since the client is unresponsive. d. Maintain continuous monitoring of the client until a family member can be located. 77. Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse to provide for this 3-year-old child? a. Set of cloth hand puppets. b. Barbie doll and clothes. c. Duck that squeaks. d. Hand-held video game. 78. While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take? a. Call 911 immediately then begin cardiopulmonary resuscitation. b. The Heimlich maneuver using chest thrusts. c. The Heimlich maneuver using subdiaphragmatic thrusts. d. Cardiopulmonary resuscitation with uterine tilt. 79. After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next? a. Open the isolette door to assess the infant's vital signs. b. Place erythromycin opthalmic ointment in both eyes. c. Remove the wet blankets and linens from the isolette. d. Administer the vitamin K (AquaMEPHYTON) injection. 80. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? a. Reschedule administration of the antibiotic until after he completes his prayers. b. Instruct the client that the antibiotics must be given on time to be effective. c. Notify the healthcare provider that the client has refused the scheduled antibiotic. d. Ask the pharmacist to supply an oral form of the antibiotic for the client. 81. The nurse learns that a newly admitted adult client has a six month history of recurring somatic pain. During the admission interview, it is most important for the nurse to question the client about what problem ? a. Episodes of tremors. b. Feelings of depression. c. Periods of restlessness. d. Nausea and vomiting. 82. The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology, secondary to the medication's effects, places the client at risk for injury? a. Bleeding complications. b. Adverse CNS effects. c. Electrolyte imbalance. d. Immune system suppression. 83. A client who has end-stage renal disease (ESRD) continues to be despondent after receiving the biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) for 3 weeks. Which parameters should the nurse assess when evaluating the effectiveness of this BRM? a. WBCs, neutrophil and T4 count. b. RBCs, hemoglobin, and hematocrit. c. Blood pressure, heart rate, and temperature. d. Serum potassium, calcium, and phosphorus. 84. A 25-year-old male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. What is the most important information for the nurse to include in the teaching plan? a. Avoid penile contact with the rectal area. b. Epididymitis is a pre-cancerous condition. c. Obtain an annual prostate digital exam. d. Surgical intervention is often indicated. 85. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement? a. Increase the intake of salty foods. b. Administer NaCl supplements. c. Restrict oral fluid intake. d. Hold the client's loop diuretic. 86. A young adult male is brought to the emergency room with multiple gunshot wounds in the chest, abdomen, and head. After collecting the client's blood-saturated clothing as forensic evidence for the medical examiner, which action should the nurse implement? a. Fold clothing in a large specimen container and send to the pathology lab. b. Roll the clothing in a towel and cover it with an impermeable drape. c. Place the clothes in a paper bag and transfer bag to a red biohazard bag. d. Drop the clothes in a red plastic bag and maintain blood-borne precautions. 87. A male client asks the nurse how long his hospital stay will be following his scheduled surgery. Which resource provides the best guide for the nurse in responding to the client? a. Critical pathway for the scheduled surgery. b. Diagnosis-related group (DRG) for the surgery. c. The client's preferred provider arrangement. d. Standards of clinical nursing practice. 88. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client? a. Disturbed thought processes. b. Altered sleep pattern. c. Imbalanced nutrition: less than. d. Risk for injury. 89. The nurse-preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify? a. Warm skin, hypertension, and constricted pupils. b. Bradycardia, hypotension, and respiratory acidosis. c. Mottled skin, tachypnea, and hyperactive bowel sounds. d. Tachycardia, mental status change, and low urine output. 90. Prior to obtaining an axillary temperature, the nurse should perform which action? a. Check the last oral temperature reading. b. Ask the client when he last ate or drank. c. Place a protective sheath over the thermometer. d. Position the client's arm at heart level. 91. When is the best time for the nurse to assess a client for residual urine? a. When the client's bladder is distended. b. Immediately after the client voids. c. Just prior to the client voiding. d. After draining the urinary catheter bag. 92. Which finding should raise the greatest concern for a nurse who is performing an ENT examination? a. A painful ulcerated mucosal area inside the cheek for 1 day. b. Stippled gingival margins that adhere firmly to the teeth. c. A number of small yellowish-white and raised lesions on the buccal mucosa. d. An ulceration under the tongue that has been present for the last three weeks. 93. During a home visit, the nurse should evaluate the adequacy of a client's treatment for COPD by assessing for which primary symptom? a. Dyspnea b. Tachycardia. c. Unilateral diminished breath sounds. d. Edema of the ankles. 94. The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene? a. An Asian-American mother reports using cupping to treat infection, resulting in a pattern of red round marks on her toddler's back. b. A Hispanic pregnant client who is often late for appointments, arrives late for today's appointment. c. A Native-American who is being interviewed will not make direct eye contact when asked about violence in the home. d. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit. 95. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling "out of breath" but denies any other complaints. What action should the nurse take at this time? a. Administer a PRN prescription for diphenhydramine (Benadryl). b. Start the normal saline attached to the Y- tubing at the same rate. c. Decrease the intravenous flow rate of the PRBC transfusion. d. Ask the respiratory therapist to administer PRN albuterol (Ventolin.). 96. The nurse observes that a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement? a. Discontinue the IV and apply pressure at the site. b. Decrease the saline to a keep-open rate. c. Increase the rate of the current IV solution. d. Change the IV fluid to 0.45% normal saline at the same rate. 97. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time? a. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant. b. Help the client place a call to the HMO to seek information about limitations of coverage. c. Encourage the client to call a lawyer so that a lawsuit can be filed against the HMO if necessary. d. Have the social worker call the state board of insurance to register a complaint against the HMO. 98. The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel a. Remove the glass of water and speak to the UAP. b. Discuss the incident with the UAP at the end of the day. c. Write an incident report and notify the healthcare provider. d. Remind the client of the potential for electrolyte imbalance. 99. Which assessment is most important for the nurse to complete to determine a client's tolerance for ambulation? a. Respiratory rate. b. Capillary refill. c. Pedal pulses. d. Skin turgor. 100. A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first? a. Provide a supportive, structured environment for meals. b. Assess weight, vital signs, potassium and other electrolytes. c. Discuss alternative strategies for binging and purging. d. Monitor the client after meals for possible vomiting. 101. Which symptom in a client with fractured ribs would indicate the presence of an abnormality warranting immediate intervention by the nurse? a. Complaints of chest pain with movement. c. Shallow respirations and refusing to take deep breaths. b. Ecchymosis around fracture site. c. Asymmetrical chest wall excursion. 102. A 62-year old male client with a history of coronary artery disease complains that his heart is "racing" and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, the nurse should administer which prescription? a. Give magnesium per secondary infusion. b. Initiate IV heparin solution per protocol. c. Administer IV adenosine (Adenocard). d. Prepare for synchronized cardioversion. 103. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust? a. Explain that distrust is related to feeling anxious. b. Initiate short, frequent contacts with the client. c. Explain that these beliefs are related to her illness. d. Offer to keep the belongings at the nurse's desk. 104. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe? a. Nitrofurantoin (Macrodantin) orally. b. Erythropoietin (Epogen) intravenously. c. Kayexalate retention enema. d. Azathioprine (Imuran) orally. 105. A client with late stage rheumatoid arthritis frequently drops the silverware while eating. Which resource would be of greatest value to this client? a. A UAP to help feed the client. b. An Occupational Therapist. c. A Physical Therapist. d. A Registered Dietician. 106. The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Place a small pillow under the infant's head while lying on the back. b. Turn the infant on the left side braced against the crib when sleeping. c. Prop the infant in a sitting position with a cushion when not sleeping. d. Position the infant on the stomach occasionally when awake and active. 107. During a preoperative appointment at an ambulatory surgery center, a client expresses anxiety to the nurse about the impending surgery. How should the nurse respond? a. "It is very normal to feel anxious before a surgical procedure." b. "Let me sit down with you and explain the surgical procedure." c. "Tell me what concerns you have about your upcoming surgery." d. "Medication will be available if you experience any pain after surgery." 108. The nurse is planning to administer a Mantoux test to determine if the client has been infected with the tuberculosis bacilli. What is the correct interpretation by the nurse? a. A positive reaction indicates that active disease is present in the body. b. The test should be read within 24 hours of administration. c. Induration noted by inspection and palpation confirms a significant reaction. d. A reaction of 0 to 4 mm is considered significant and requires further investigation. 109. The nurse is communicating with a 12-year-old who is hearing impaired. What action is best for the nurse to use when attempting to communicate with this child? a. Convey ideas by writing short sentences. b. Emphasize emotions with facial expressions. c. Attract the child's attention before speaking. d. Use a picture board to communicate needs. 110. The nurse anticipates the prescription of a reduced dosage of a nephrotoxic medication for the client with which problem? a. Documented presence of a kidney cyst found via ultrasound. b. Observable hematuria following a renal biopsy procedure. c. Subjective reports of dysuria with burning pain and cloudy amber urine. d. Diminished creatinine clearance found after 24-hour urine collection. 111. The nurse is assessing a client's central venous pressure (CVP) via a pulmonary artery (PA) catheter port. The client is in a supine position with the head of the bed at a 45 degree angle. The CVP reading is 6 mmHg higher than the previous reading. To evaluate the reading, what action should the nurse take first? a. Verify the recorded bed position of the last reading. b. Evaluate the client's 24 hour intake and output. c. Reposition the client and reassess the reading. d. Report the pressure to the healthcare provider. 112. While inserting an indwelling urinary catheter in a female client, the nurse observes urine flow in the tubing. What action should be taken next? a. Document the color and clarity of the urine. b. Insert the catheter an additional inch. c. Inflate the balloon with 5 ml of sterile water. d. Ask the client to breathe deeply and slowly exhale. 113. The first time a male client stands at the bedside following a total hip replacement, he reports severe pain in his left calf. What intervention should the nurse take first? a. Remind the client of the importance of postoperative mobility. b. Use a pain scale to evaluate the severity of the pain. c. Return the client to bed and assess the lower extremities. d. Transfer the client to a chair and elevate the lower extremities. 114. A 10-year-old boy is admitted to Neuro Intensive Care following a supratentorial craniotomy. What postoperative intervention should the nurse plan to implement? a. Elevate the client's head of bed to 30 degrees. b. Teach the child about patient controlled analgesia (PCA). c. Administer IV D5 / 0.25 NS via pump at 125 ml/hr. d. Remove the surgical dressing to assess for bleeding. 115. Which finding in an elderly female client who was started on digoxin (Lanoxin) 0.25 mg indicates that the medication is producing a therapeutic effect? a. Increased heart rate. b. Decreased cardiac output. c. Increased kidney perfusion. d. Decreased cerebral perfusion. 116. The nursing diagnosis, "High risk for infection" is most relevant for a client with which hematologic problem? a. Agranulocytosis b. Thrombocytopenia. c. Erythrocytopenia. d. Polycythemia. 117. The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first? a. Check the probe position. b. Administer oxygen by face mask. c. Notify the healthcare provider. d. Reset the alarm. 118. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? a. Synovial fluid analysis. a. Synovial fluid analysis. b. Lumbar puncture. c. Electroencephalogram (EEG). d. Cervical x-rays. 119. Following a traumatic delivery, an infant receives an initial Apgar of 3. What intervention is most important for the nurse to implement? a. Continue resuscitative efforts. b. Inform the parents of the infant's condition. c. Repeat the Apgar assessment in 5 minutes. d. Page the pediatrician STAT. 120. After administering the initial dose of enalapril (Vasotec) to a female client, it is most important for the nurse to assist the client with which activity? a. Ambulation in the room and hallway. b. Feeding the client her next meal. c. Cough and deep breathing exercises. d. Mouth and skin care measures. 121. The charge nurse working on a rehabilitation unit is making client assignments for 2 registered nurses (RN) that have been in the department over 3 years, and one new RN graduate who completed orientation this week. Which client should the charge nurse assign to the new RN graduate? The client a. with a T-12 spinal cord injury who is being transferred from the neurological unit. b. with a head injury who is being discharged home with multiple referrals. c. whose family is meeting with the rehabilitation team to discuss a treatment plan. d. with a total knee replacement who has 3 hours of prescribed physical therapy. 122. A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam (Zosyn) for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose? a. Presence of gram positive bacteria in the sputum. b. Elevated white blood cell count. c. Decreased creatinine clearance. d. Decreased serum potassium. 123. In teaching a client with Parkinson's disease, the nurse describes what rationale for the prescription of levodopa-carbidopa (Sinemet)? This drug a. acts as an antiseizure medication, reducing the tremors caused by the disease. b. increases the amount of dopamine, needed for muscles to function correctly. c. slows the scarring in the myelin sheath, improving muscle tone and strength. d. reduces the inflammatory process, improving nerve transmission and function. 124. A male client who has been immobilized for four days because of multiple broken bones following a motor vehicle collision is admitted from the intensive care unit to the medical unit of an acute care hospital. What assessment data are most important for the nurse to obtain within the first hour of admission? a. Skin integrity and nutritional status. b. Tolerance for moving in bed and performing ROM exercises. c. Blood pressure and white blood cell count. d. Temperature and breath sounds. 125. Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia? a. Recent joint trauma. b. Disruption in sleep patterns. c. Unexplained weight gain. d. Itching and rash. 126. An alert and oriented client requiring droplet precautions is placed in a private room at the end of the hallway. Several days later, the nurse finds that the client is restless and anxious. What action should the nurse implement? a. Transfer the client to a semi-private room closer to the nurse's station. b. Encourage family members to maintain a regular visitation schedule. c. Advise unit personnel to enter the client's room only when necessary. d. Obtain a prescription for a vest restraint from the healthcare provider. 127. The nurse is performing an admission assessment on an HIV positive client with a diagnosis of Pneumocystis carinii pneumonia (PCP). The nurse should carefully observe the client for which symptoms? a. Weight loss exceeding 10 percent of baseline body weight. b. Creamy white patches in the oral cavity. b. Altered mental status and tachypnea. c. Normal ABGs, with wet lung sounds in all lung fields. 128. A 3-year-old with HIV infection is staying with a foster family who is caring for three other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first? a. Review the immunization documentation of the child with HIV. b. Report the exposure of the child with HIV to the Health Department. c. Remove the child who has HIV from the foster home. d. Place the child who has HIV in reverse isolation. 129. The healthcare provider prescribes an excessive amount of morphine sulfate IV push to be given to a terminally ill client. What is the priority intervention for the nurse to implement? a. Refuse to administer the medication. b. Report the prescription to the medical director. c. Report the incident to the medical ethics committee. d. Obtain permission from the family prior to administering. 130. A 2-year-old child with celiac disease experiences a relapse of symptoms. In developing a teaching plan for the child's family, which topic should be the nurse's primary focus? a. Dietary management. b. Chronic disease adaptation. c. Perianal skin care. d. Disease complications. 131. Which client situation requires the most immediate intervention by the nurse? a. A six centimeter area of reactive hyperemia is observed over the left trochanter of a bedfast client. b. A four centimeter area of dehiscence is observed on a client's abdominal incision one day after surgery. c. A stage II pressure ulcer located on a client's sacrum is draining a moderate amount of purulent drainage. d. A stage IV pressure ulcer has a five centimeter area of necrosis surrounded by pale pink tissue. 132. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? a. Cleanse the foot with soap and water and apply an antibiotic ointment. b. Provide teaching about the need for a tetanus booster within the next 72 hours. c. Have the mother check the child's temperature q4h for the next 24 hours. d. Transfer the child to the emergency department to receive a gamma globulin injection. 133. An 84-year-old female resident of an assisted living center has become increasingly withdrawn from her friends, cries often, and asks the nurse to call her daughter three times a day. The nurse's plan of care should be based on the knowledge that the resident is exhibiting behaviors consistent with which of Erikson's stages? a. Satisfaction vs. Depression. b. Integrity vs. Despair. c. Trust vs. Mistrust. d. Intimacy vs. Isolation. 134. The nurse assesses an adult client who has a sigmoid colostomy following a bowel exploration performed yesterday. Which assessment finding should be reported to the surgeon immediately? a. The fecal matter is brown and has a solid consistency. b. The stoma mucosa is purple in color. c. The stoma has streaks of bright red blood. d. There are no bowel sounds in the left lower quadrant. 135. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid? a. One-half liter. b. One liter. c. Two liters. d. Three liters. 136. The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one registered nurse (RN) with 10 years experience, one RN with 5 years experience, and a new graduate RN who just completed a 12-week internship. Which client should the nurse assign to the new graduate RN? a. A client in end-stage liver failure who is experiencing esophageal bleeding. b. A client with multisystem failure secondary to a motor vehicle collision. c. A client with chest tubes secondary to a stab wound to the chest. d. A client with Adult Respiratory Distress Syndrome who is on a ventilator. 137. The mental health nurse working in a community treatment center is preparing an educational presentation on medication administration, and plans to use photographs of clients to demonstrate certain medication principles. Which intervention is most important for the nurse to implement? a. Identify which psychotropic medications will be used in the presentation. b. Determine if the clients have allergies to the medications being demonstrated. c. Obtain written consent from each client to take their personal picture. d. Assess the client's understanding of why the presentation is being prepared. 138. The nurse enters a male client's room to administer a subcutaneous dose of enoxaparin sodium (Lovenox), a low molecular weight heparin. The client is lying supine in bed. What action should the nurse implement? a. Roll up the sleeve of the client's hospital gown to fully expose his upper arm. b. Elevate the head of the bed and look for any bruising around the umbilicus. c. Ask the client if he can tolerate lying on his abdomen for a short period of time. d. Observe the sides of the client's abdomen while he remains in a supine position. 139. A high-school girl asks the school nurse what to do about her fingernails that look "so awful" since she had her artificial nails removed 6 weeks ago. On inspection, the nurse finds the girl's nails are thickened, cracked, and yellowing. What instruction should the nurse provide? a. Do not use manicure products that dry the nails. b. Use a prescribed systemic antifungal medication. c. Keep nails short and trimmed straight across. d. Avoid harsh chemicals and abrasives on the nails. 140. The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's teaching plan? a. Regular aerobic exercise. b. Weight-bearing activities. c. Abdominal wall strengthening. d. Pelvic floor exercises. 141. A client receiving warfarin (Coumadin) develops hematuria. What is the priority nursing action? a. Obtain a urine specimen for urinalysis. b. Instruct the client to increase oral fluid intake. c. Monitor the client's serum prothrombin time/INR. d. Assess the next bowel movement for occult blood. 142. While making a home visit, the nurse observes that a male client who is on a sodium restricted diet is drinking herbal tea and using a salt substitute to flavor his breakfast of scrambled eggs and smoked ham. What instruction should the nurse provide? a. Replace the ham with toast and jelly. b. Substitute mixed fruit for the eggs. c. Avoid daily use of the salt substitute. d. Drink orange juice instead of herbal tea. 143. While administering a pneumococcal vaccine to an older adult, the nurse provides teaching about methods to prevent pneumonia. Which instruction should the nurse include? a. Engage in regular leg exercises while sitting. b. Enroll in a smoking cessation program. c. Take a small dose of aspirin daily. d. Adhere to a low sodium diet. 144. A male client with chronic pain reports minimal pain relief despite attempts to adhere to the pain relief measures he was taught. He appears withdrawn and refuses to be involved with planning his care. The nurse should identify which problem as having the highest priority? a. Hopelessness. b. Self-care deficit. c. Knowledge deficit. d. Noncompliance. 145. The nurse is supervising an unlicensed assistive personnel (UAP) who is preparing to provide catheter care for a client with an indwelling urinary catheter. The UAP has obtained sterile gloves and the supplies needed to clean the area. What action should the nurse take? a. Advise the UAP that exam gloves can be used rather than sterile gloves. b. Assign the UAP to another task while the nurse completes the procedure. c. Acknowledge that the UAP is well prepared to maintain aseptic technique. d. Assist the UAP in setting up the sterile field before the procedure is started. 146. The RN case-manager working in a home health care agency is making client assignments. Which client should the case-manager assign to a newly hired RN with 3 years acute care experience? The client a. diagnosed with heart failure who needs an admission assessment. b. who needs an intravenous antibiotic via a subclavian line. c. who is being discharged from home health care after 3 months. d. who is requesting information about a hospice referral. 147. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency room with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? a. Hypotension and venous pooling in the extremities. b. Profuse diaphoresis and severe, pounding headache. c. Complaints of chest pain and shortness of breath. d. Pain and a burning sensation upon urination and hematuria. 148. A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing diagnosis has the highest priority? a. Risk for injury related to uterine atony. b. Ineffective breastfeeding related to fatigue. c. Impaired parenting related to inexperience. d. Acute pain related to abdominal incision. 149. A male client's lithonate (Lithium) prescription was increased a month ago, and his current lithium level is 0.54 mEq/L. When calling the client to report the laboratory findings, which question is most important for the nurse to ask? a. "Have you been taking your lithium every day?" b. "Are you having any side effects from the lithium?" c. "Do you have any concerns about your lithium?" d. "Are you willing to have another lithium level done?" 150. The nurse is pouring a bottle of sterile solution into a container on a sterile field that is set up on a client's bedside table. Which action is in keeping with the principles of surgical asepsis? a. Avoid spilling or splashing the solution when pouring. b. Apply sterile gloves prior to pouring the solution. c. Remove the solution cap and place it on the sterile field. d. Place the bottle of solution behind the sterile container. 151. A client who had a left above knee amputation (AKA) two days ago has a soft stump dressing in place. To prevent the development of a contracture on the left leg, which intervention should the nurse implement? a. Elevate the client's left leg on two pillows at all times. b. Instruct the client to push the stump against a soft pillow. c. Position the client prone 3 to 4 times a day. d. Turn the client to the unaffected side only. 152. The nurse overhears two hospital employees discussing confidential client information in the cafeteria. The nurse decides to intervene, because this situation is a breach of which ethical principle? a. Veracity b. Consistency. c. Autonomy d. Fidelity. 153. A middle-aged female client is admitted to the Emergency Department after fainting while working outside and perspiring on a hot summer day. Assessment findings indicate that she is tachycardic with a blood pressure of 96/68, and her serum sodium level is 128 mEq/L. Which prescription should the nurse implement first? a. Insert indwelling catheter. b. Normal saline IV at 125 ml/hour. c. Continuous telemetry. d. Obtain a cerebral CAT scan today. 154. Following a total thyroidectomy, the nurse plans to observe a client for complications; in particular, for development of hypoparathyroidism. What finding indicates that the client has developed this complication? a. Complains of back and joint tenderness and pain. b. Complains of muscle twitching in hands and feet. c. Denies muscle spasms in extremities. d. Diaphoretic, but denies any headache. 155. A 30-year-old female client with a history of fibrocystic breast disease is seeking care because of a pea-sized, painful lump she discovered in her left breast three weeks ago. She is anxious, and states that she is sure she has cancer. Which response is best for the nurse to provide? a. "Don't worry, this is probably not cancer because the lump is small and painful." b. "It could be cancer. We won't know until you see a surgeon and a biopsy can be performed." c. "Your risk of cancer is low, but you did the right thing coming in to seek more information." d. "With your history, you should have sought follow-up assessment as soon as you noticed the lump." 156. A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. Encourage him to initiate daily rituals. b. Reinforce the reality of his financial situation. c. Direct him to drink a glass of red wine at bedtime. d. Teach him to limit sugar and caffeine intake. Completion Complete each sentence or statement. 157. Ampicillin (Ampicin) 1 gram IV q4h is prescribed for a 38 week multipara how is positive for Group B streptococcus. The drug is available via the Ptyxis system diluted in 50 ml of normal saline. To admister the medication over 30 minutes, the nurse should set the infusion pump to deliver how many ml/hr? (Enter numerical value only) 158. A client weighing 176 pounds is started on a weight-based heparin protocol. The pharmacy provides 500 ml D5W with 25,000 units of heparin. The sliding scale prescription reads: "Begin the infusion for the client weighing 74-80 kg to infuse at 1000 units/hr; more than 80 kg infuse at 1,200 units/hr; less than 74 kg infuse at 800 ml/hr." The nurse should regulate the infusion pump at how many ml/hour? (Enter numerical value only.) 159. The nurse plans to administer two preoperative medications to a client in a single syringe. The prescription is for meperidine (Demerol) 75 mg and promethazine (Phenergan) 25 mg. The Demerol is contained in a vial labeled 100 mg/ml, and the Phenergan is in a vial labeled, "25 mg/ml." How many total ml will the syringe contain that the nurse administers to this client? (Enter numerical value only. If rounding is required, round to the nearest hundredth.) 160. A 16-year-old male is admitted after a motor vehicle collision with 50% burns over his body. One liter of normal saline is prescribed to infuse over 4 hours. The drop factor is 60 drops per ml. The nurse should regulate the infusion to administer how many drops per minute? (Enter numerical value only.) [Show More]

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