ATI PN Comprehensive Test 2,Answered (2020)

NURS 493 ATI PN Comprehensive Test Bank 2 A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? ...

NURS 493 ATI PN Comprehensive Test Bank 2 A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Vomiting b. Hypertension c. Epigastric pain d. Contractions A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? e. Stay in bed at least 1 hr if unable to fall asleep f. Take a 1 hr nap during the day g. Perform exercises prior to bedtime h. Eat a light snack before bedtime A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular tachycardia. Which of the following actions should the nurse take first after determining the client does not have a palpable pulse? i. Assess heart sounds j. Defibrillate k. Establish IV access l. Administer epinephrine A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client. The client’s partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s admission data? m. Have the client’s child translate n. Allow the client’s partner to translate o. Request a female interpreter through the facility p. Ask a nursing student who speaks the same language as the client to translate A nurse is caring for a client who is febrile (High fever). To reduce the client’s fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling? q. Flushing r. Tachycardia s. Restlessness t. Shivering (Hypothermic) A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Exhibit) u. Position the client with the affected extremity lower than the heart v. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin w. Administer acetaminophen x. Massage the affected extremity every 4 hr A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietitian? y. An older adult client who has a BMI of 24 (18.5-24.9) z. A client who has a nonhealing leg ulcer (diet isn’t good) aa. An older adult client who has presbyopia (age related far-sightness) bb. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4) A nurse is providing discharge teaching to a client who has a chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? cc. Eat 1 g/kg of protein per day dd. Take magnesium hydroxide for indigestion ee. Drink at least 3 L of fluid daily- ff. Consume foods high in potassium- restrict 2. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. Sitting in a high-Fowler’s position during the feeding b. A history of gastroesophageal reflux disease c. Receiving a high osmolarity formula d. A residual of 65 mL 1 hr postprandial? 3. ?A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client that she will undergo which of the following screening tests at 16 weeks of gestation? a. Chorionic villus sampling- as early as 8 weeks b. Cervical cultures for chlamydia- 1st appointment. c. Nonstress test -28 weeks d. Maternal serum alpha-fetoprotein- 16 to 18 weeks 4. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? a. Decreased serum calcium levels- increased serum calcium b. Increased blood pressure- hypotension c. Swollen area on calf d. Urinary frequency- 5. A nurse in acute care mental health facility is participating in a medication-education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? a. The leader encourages group members to remain silent until questions are called for b. The leader lecture about medication adverse effects to the group members c. The leader allows the group to discuss whatever they would like to regarding their medications d. The leader has group members vote on what they would like to learn about during the session 6. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? a. “You can add the medication to a half-cup of your child’s favorite juice.” b. “Repeat the dose if your child vomits within 1 hour after taking medication.” X c. “Limit your child’s potassium intake while she is taking this medication.” d. “Have your child drink a small glass of water after swallowing the medication.” 7. A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid? a. Grapefruit b. Spinach c. Cottage cheese- cream cheese ok. d. Smoked salmon TYRAMINE! 8. A nurse is planning care for a client who has COPD and weighs 99 lb. The provider has prescribed a diet of a 1.5 g protein/kg/day. How many grams of protein per day should the nurse include in the client’s dietary plan? (Round to the nearest whole number) a. 68 9. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? a. Encourage the client to spend time in the day room b. Withdraw the client’s TV privileges if he does not attend group therapy c. Encourage the client to take frequent rest periods d. Place the client in seclusion when he exhibits signs of anxiety 10. A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session? a. Initiate a discussion with clients about ways to cope with changes in family dynamics b. Encourage clients to establish a timeline for their own grieving process c. Discourage clients from sharing negative aspects of their relationship with the deceased persons d. Assist clients in identifying ways suicide could have been prevented 11. A nurse manager observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following actions should the nurse manager take first? a. Instruct the nurses to close the client’s computer record b. Request the nurses present an in-service on client confidentiality c. Advise the nurses to read the facility’s confidentiality policy d. Place documentation of the nurses’ actions in the personnel file 12. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. Heart rate 58/min b. Fasting blood glucose 100 mg/dL c. Hgb 14 g/dL d. WBC count 2,900/mm3- also agranulocytosis same thing or soar throat. Clozapine has to do with WBC bruh 13. A nurse is caring for several clients on a medical-surgical unit. For which of the following nurses activities is it required that the nurse use sterile gloves? a. Inserting an NG tube b. Administering total parenteral nutrition through a central venous access device c. Initiating IV access d. Performing tracheostomy care 14. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse ? a. Influenza b. Measles, mumps and rubella c. Human papilloma virus d. Varicella 15. A nurse is inserting an indwelling catheter for a male client. Which of the following actions should the nurse take? a. Perform the cleansing procedure with a fresh swab two times b. Lift the penis so that it is perpendicular to the client’s body c. Cleanse the tip of the penis in a side-to-side motion d. Pick up the catheter 13 cm (5 cm) from its tip 16. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? a. Bleeding gums- low platelet b. Faintness upon rising c. Swelling of the face d. Urinary frequency 17. A nurse has received change-of-shift report for a group of clients. Which of the following actions should the nurse take to manage time effectively? a. Document client care at the end of the shift b. Make the client to-do list for the day c. Skip breaks until the client tasks are completed d. Focus on several client tasks at a time 18. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Minimize noise in the newborn’s environment b. Administer naloxone to the newborn c. Swaddle the newborn with his legs extended d. Maintain eye contact with the newborn during feedings 19. A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? a. The anterior fontanel is open b. The posterior fontanel is open c. Both fontanels are the same size d. Both fontanels show molding 20. A nurse is caring for client who has acute diverticulitis (low fiber) . Which of the following diets should the nurse recommend to the client? Diverticulosis- High fiber a. High residue b. Lactose-free c. Gluten-free d. Low-fiber 21. A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse include in the plan of care? a. Administer low-dose heparin b. Place the client on a full liquid diet c. Use an incentive spirometer every 3 hr d. Maintain the client on bed rest 22. A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching? a. Burp the infant frequently during feedings b. Position the nipple at the front of the infant’s mouth c. Hold the infant in a supine position d. Use feeding devices without nipples 23. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who depressive disorder and requires assistance with ADLs b. A client who has obsessive-compulsive disorder and is upset about a change in a daily routine c. A client who is taking clozapine to treat schizophrenia and reports sore throat d. e. A client who has narcissistic personally disorder and is mocking other during group therapy 24. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Develop an hourly time frame for tasks b. Schedule daily activities c. Determine goals of the day d. Delegate tasks to the AP 25. A nurse is performing an admission assessment for a client who is in the manic phase of bipolar disorder. Which of the following behaviors should the nurse expect? a. Performance of ritualistic behaviors- ocd b. Suspiciousness and distrust- schizo c. Distractibility and poor judgment d. Reports of physical discomfort -anxiety 26. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Weak femoral pulses?- they get upper extremity hyper, lower extremity hypo b. Frequent nosebleeds- yes c. Upper extremity hypotension d. Increased intracranial pressure 27. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? a. “The client might act seductively”- histrionic b. “The client is overly concerned about minor details”- ocd c. “The client exhibits impulsive behavior” d. “The client is exceptionally clingy to others”- dependent 28. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? TIDLING IN WATER SEAL AND CONTINUOUS IN SUCTION CHAMBER OKAY! WATER SEAL BUBBLING IS AIR LEAK. a. There is a loop of tubing below the drainage system b. The system is working properly c. The lung has re-expanded d. The tubing is partially obstructed by clots 29. A nurse in an emergency department is caring for a client who is experiencing stimulant withdrawal. Which of the following findings should the nurse expect? a. Runny nose b. Decreased appetite -Increased appetite c. Muscle spasms d. Fatigue, depression, agitated, anxiety, craving, increased appetite 30. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. A history of being in prison b. Experiencing delusions c. Male gender d. Previous violent behavior 31. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing X b. Talk to the client during feeding X c. Discourage the client from coughing during feedings d. Sit at or below the client’s eye level during feedings 32. A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? a. “I expect this medication to raise my blood pressure” b. “I should take this medication on an empty stomach” c. “I can continue to take St. John’s wort while taking this medication” d. “I know it will be a couple of weeks before the medication helps me feel better” 33. A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care? a. Ambulate the client before each meal b. Offer the client three large meals each day X c. Administer a bronchodilator after meals d. Limit fluid intake with meals YES drinking before and after can bloat you 34. A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Exhibit) a. Encourage the client to verbalize feelings * Assess for hopelessness b. Implement seizure precautions for the client c. Administer ondansetron to the client for nausea d. Obtain the client’s weight 35. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? a. A client who lives with family members and begins to take more responsibility of self-care b. A client who reports being given sedative medications by family members c. A client who is taking warfarin and has several small bruises on her shins and hands d. A client who schedules multiple visits with his provider every month 36. A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care? ALTEPLASE TREATS STROKES, HEART ATTACKS AND CLOTS. a. Administer medications intramuscularly X- it is IV b. Provide a diet low in protein X- why c. Observe for bruising of the skin- check for bleeding d. Monitor vital signs every hour for the first 4 hr- X every 15 min for the first hour 37. A nurse is caring for a client who is postoperative following an appendectomy and is receiving gentamicin. Which of the following assessment findings should the nurse identify as an adverse effect of this medication? a. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity b. Respiratory rate 22/min c. 2+ pitting edema of the ankles d. Hgb 8.7 g/dL 38. A nurse in an acute care facility is caring for a client who is homeless and has a decubitus ulcer. Which of the following actions should the nurse take as a client advocate? a. Gather dressing supplies for the client’s discharge b. Provide client teaching about nutrition c. Consult with the facility’s quality improvement team d. Contact the facility’s case management department? 39. A nurse is caring for client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? a. Discard the open can of formula after 36 hr- b. Administer feedings at a slower rate---can give d10W. c. Flush the tube with 10 mL of water after feedings d. Provide chilled formula- room temperature 40. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? a. Withhold the medication if the client does not appear to be in pain b. Withhold the medication if the client has a fever c. Document administration of the medication upon removal from the medication dispensing system d. Count the current number of unit doses available in the medication dispensing system 41. A nurse in a provider’s office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. Herpes zoster b. Hypertension c. Obesity d. Hypothyroidism 42. A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider? a. Temperature 37.6 C (99.7 F) b. Urinary output 20 mL/hr c. Blood pressure 100/70 mm Hg d. Serious drainage on abdominal dressing 43. A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury? a. Place the bedside table at the foot of the bed b. Keep the television on during the night c. Assist the client to the toilet frequently d. Raise the side rails up when the client is in bed 44. A certified IV nurse is providing education about peripherally inserted central catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “Use a vein in the middle of the lower arm to insert a PICC”- above elbow, below shoulder b. “Flush a PICC using a 3-mililiter syringe”- 10 mL c. “Informed consent is required prior to a PICC placement” d. “Position the client’s arm in adduction for PICC placement” 45. A nurse is teaching self-administration of insulin glargine to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take this insulin before meals” b. “I will not mix this insulin with other types of insulin” c. “I will rotate the injection sites between my a`rm and my thigh” (abdomen) d. “I will shake the vial to mix the insulin” (you must roll) 46. Hotspot : Lower lobe base- pneumonia assessment where to auscultate 47. A nurse is caring for a client who is immunocompromised. Which of the following antiseptic solutions should the nurse use to perform hand hygiene? a. Isopropyl alcohol b. Bleach c. Chlorhexidine d. Povidone-iodine 48. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? (exhibit) a. Place the client on a cooling blanket b. Obtain arterial blood gas levels c. Elevate the head of the client’s bed to 30 d. Administer an analgesic 49. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. “This test should be performed after your baby is 24 hours old” b. “A nurse will draw blood from your baby’s inner elbow” c. “Your baby will be given 2 ounces of water to drink prior to the test” d. “This test will be repeated when your baby is 2 months old” 50. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? a. “I can visit my nephew who has chickenpox 5 days after the sores have crusted” b. “I can clean my cat’s litter box during my pregnancy” c. “I should take antibiotics when I have a virus” d. “I should wash my hands for 10 seconds with hot water after working in the garden” 51. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Primary glaucoma b. Amputation c. Hypertension d. Osteoarthritis 52. A home health nurse is planning care for a client who has Alzheimer’s disease. Which of the following actions should the nurse include in the plan of care? a. Replace the carpet with hardwood floors b. Place locks at the tops of exterior doors c. Wear clothing with zippers instead of buttons? d. Encourage physical activity prior to bedtime 53. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personal (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of of the following torts? a. Malpractice b. Negligence c. Assault d. Battery 54. A nurse is reviewing a client’s laboratory results prior to surgery. Which of the following findings should the nurse report to the provider? a. Bicarbonate 26 mEq/L--- 22-28 norm calcium 8-10 b. Chloride 100 mEq/L -- norm is 96-106 c. Potassium 3.8 mEq/L norm 3.5-5 d. Sodium 160 mEq/L – norm is 135-145 55. A charge nurse is evaluating a newly licensed nurse’s understanding of advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of advance directives? a. “I’ll refer clients who do not have advance directives for legal assistance” b. “I have to witness a client’s signature on his advance directives” c. “I have to document whether or not a client has prepared his advance directives” d. “I’ll encourage clients to follow their provider’s wishes for end-of-life care” 56. A clinic nurse is assessing an 8-year-old child during an annual physical examination. Which of the following findings indicates the need for intervention by the nurse? a. The client eats at least one snack daily b. The client’s height has increased by 6.35 cm (2.5 in) 2 inches/year c. The client’s weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs d. The client drinks 3 cups of 1% milk per day 57. A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? a. Presence of a bloody show b. Intermittent, painless contractions c. Slow change in dilation and effacement d. Contraction intensity increased by ambulation 58. A nurse is caring for a client who has a urinary tract infection and has been taking cefaclor. Which of the following serum laboratory results indicates the medication is effective? a. Creatinine 2.3 mg/dL b. BUN 32 mg/dL c. Eosinophils 3.9% d. WBC 9,200 mm3 59. A charge nurse is mentoring a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates the need for intervention by the charge nurse? a. Uses an IV infusion pump to administer total parenteral nutrition to a client b. Inserts an NG tube for a client using clean technique c. Crushes an Sub Lingual tablet to administer into a client’s feeding tube d. Stabilizes a client’s indwelling urinary catheter with the nondominated hand prior to inflation of the balloon 60. A nurse is reviewing laboratory results for a client who has a heart failure and notes a serum potassium level of 5.2 mEq/L. Which of the following medications should the nurse withhold? a. Furosemide b. Spironolactone c. Atorvastatin d. Metoprolol 61. A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching? a. “Biofeedback stimulates certain pressure points to relax muscles” b. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation” c. “Biofeedback requires concentration to control physiological responses” d. “Biofeedback uses herbs to reduce inflammation” 62. A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching? a. “Give the child acetaminophen for pain following the procedure” b. “Ensure the child’s hair is clean and without conditioner before the procedure” c. “Keep the child out of the sun for 4 hr following the procedure” d. “Make the child NPO before the procedure” 63. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. “This type of seizure can be mistaken for daydreaming” b. “This type of seizure lasts 30 to 60 seconds” c. “The child usually has an aura prior to onset” d. “This type of seizure has a gradual onset” 64. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram” X not within 12 hours b. “I will take my lithium on an empty stomach” X with food c. “I will take the sustained-release methylphenidate every morning” d. “I will avoid foods containing tyramine while taking fluoxetine” ssri X 65. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (Select all that apply) a. Foul perineal odor? b. Lochia serosa c. Postpartum d. Fundus displaced to the right e. Fundus 4 cm (1.6 cm) below the umbilicus decends 1cm per day 66. A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications a. Vitamin K b. Ranitidine c. Metoclopramide d. Vitamin B12- lifelong 67. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Hold hand flat to perform percussions on the child- cup shape b. Perform the procedure twice a day c. Administer a bronchodilator after the procedure d. Perform the procedure prior to meals 68. A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take? a. Contact the adolescent’s parent for assistance b. Advise the adolescent to place the newborn for adoption c. Assist the adolescent in applying for Medicaid d. Refer the adolescent to a local mental health clinic 69. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? a. Contact the family regarding the client’s condition b. Notify risk management c. Privately interview the client about her condition d. Inform the transferring agency of the client’s condition 70. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a cerebrovascular accident. Which of the following actions by the nurse best promotes communications among staff caring for the client? a. Noting changes in the treatment plan in the client’s medical record b. Recording the client’s progress in the nurses’ notes c. Posting swallowing precautions at the head of the client’s bed d. Having interdisciplinary team meetings for the client on a regular basis 71. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? a. Empty the collected urine once every 24 hr b. Hang the drainage bag on a bed rail c. Provide perineal hygiene after defecation d. Change the indwelling catheter every 8 hr 72. A nurse is assisting a client who has acute glomerulonephritis to choose menu items for breakfast. Which of the following food choices should the nurse recommend? a. Eggs b. Banana X c. Smoked salmon X d. Bagel 73. A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Helping clients understand health screenings covered by their insurance plans b. Using an electronic messaging system to remind clients when to take medications c. Educating clients about contraindications to specific immunizations d. Providing clients with information about the benefits of exercise 74. A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiating a referral to which of the following members of the interprofessional care team? a. Occupational therapist b. Respiratory therapist c. Social worker d. Speech-language pathologist 75. A nurse is performing a preoperative assessment for a client who reports having an allergy to several goods. Which of the following food allergies indicates a risk factor for a latex allergy? a. Peanuts b. Eggs c. Bananas d. Shrimp 76. A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan care? a. Measure the arm circumference above the insertion site daily b. Schedule an MRI post procedure to verify placement (Xray) X c. Administer sedation for the procedure X local anesthetic d. Use gauze to secure an arm board to involved extremity- used for midline 77. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? PRIMARY FASTEST TYPE ON ITS OWN, SECONDARY REQUIRES GRANULATION TISSUES AND CREATES SCAR TISSUES, AND TETRIARY IS DELAYED WOUND CLOSURE. a. Approximated surgical incision b. Infected laceration- TERTIARY c. Stage II pressure ulcer -SECONDARY d. Partial-thickness burn- SECONDARY 78. A nurse is performing a change-of-shift assessment. Which of the following clients has the priority finding? a. A client who has a first-degree heart block and a heart rate of 62/min b. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor c. A client who has pneumonia with a productive cough and a fever of 38.8 C (101.8 F) d. A client who has type 2 diabetes mellitus and a blood glucose of 250 mg/dL 79. A nurse on a medical-surgical unit delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP? a. Interpreting blood glucose values b. Performing postmortem care c. Explaining the steps for a 24-hr urine collection d. Assisting with low-carbohydrate diet selections 80. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses should the nurse make? a. “We can provide a copy of your records, but the therapist’s notes aren’t included” b. “I don’t think you will benefit from reviewing your therapist’s notes right now” c. “Why are you interested in seeing your therapist’s notes?” d. “Are you not happy with your treatment?” 81. A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching? a. “I will wipe my nose instead of blowing it” b. “I will remove my shoes when I’m inside my house” c. “I will floss between my teeth every time I brush” d. “I will use an enema to manage my constipation” 82. A home care nurse is making follow-up visit with a client has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take? a. Store the oxygen tank wrench in a locked cabinet b. Have the client store smaller tanks under his bed c. Ensure that the client checks the gauge weekly d. Place the oxygen tank away from curtains or drapes 83. A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? a. Renal calculi b. Fibrocystic breast disease? c. Fibromyalgia d. Hypertension 84. A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client? a. Hypokalemia b. Muscular depression c. Laryngeal stridor d. Hyperglycemia 85. A nurse is teaching a client who is to start a new prescription for =. Which of the following instructions should the nurse include? a. “Take with the protein snack” – limit protein b. “Report dark-colored urine”- this normal c. “Monitor for hyperglycemia” d. “Change positions slowly” ? 86. A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority? a. Constipation b. Sedation c. Euphoria d. Bradypnea 87. A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about managing the disease. The nurse should emphasize the importance of which of the following factors to prevent a sickle cell crisis? a. Adequate hydration b. Calorie restriction c. Increased iron intake d. A low-protein diet 88. A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks? a. Accepting the decision of an older adult client to live alone in her home b. Ensuring that a client who is homeless receives preventive medical care- be fair c. Keeping a promise to visit with a client who is housebound after the delivery of care d. Being honest with the parents of a child about the need to report suspected abuse 89. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? a. Changes in appetite b. Prescribed medications c. Swallowing ability d. Daily fluid intake 90. A nurse is caring for a client who has a new prescription for piperacillin/tazobactum 3.75 g intermittent IV bolus Q6H to infuse over 30 min. Available is piperacillin/tazobactum 3.75 g in 50 mL 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? a. 100 91. A nurse is assessing a client who has acute angle-closure glaucoma. Which of the following findings should the nurse expect? a. Increased light perception b. Reddened cornea c. Severe periocular pain d. Gray cast sclera 92. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? a. Dietitian b. Infection control nurse c. Nephrologist d. Cardiologist 93. A nurse is caring for a toddler who has retinoblastoma (cancer of eye). Which of the following findings should the nurse expect? a. Hyphema b. Opacity of the lens c. Nystagmus d. White eye reflex 94. A nurse is providing discharge teaching about home care of a surgical incision to a client who does not speak the same language as the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? a. Use gestures to convey meaning b. Speak directly to the client c. Pause in the middle of sentences d. Speak slowly when talking to the interpreter 95. A nurse is providing teaching about exercise to a client who is at 28 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching? a. “I can continue to do exercises that require the supine position” X b. “I should check my pulse rate once every hour while exercising” c. “I should increase my exercise level to prepare for labor” X d. “I should drink 16 to 24 ounces of water after I exercise” 96. A nurse is providing discharge teaching to the parents of toddler who has cystic fibrosis. Which of the following instructions should the nurse include? a. “Use a nebulizer to administer a bronchodilator following airway clearance therapy” b. “Restrict intake of foods that contain gluten” c. “Perform chest percussion and postural drainage at least twice daily” d. “Administer pancreatic enzymes on an empty stomach”- X with meal 97. A nurse is developing a plan of care for a client who has preeclampsia (high bp) and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Monitor the FHR via Doppler every 30 min b. Restrict the client’s total fluid intake to 250 mL/hr c. Give the client protamine if signs of magnesium sulfate toxicity occur d. Measure the client’s urine output every hour 98. A nurse is planning discharge teaching for a client who is to start a new prescription for metoprolol. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Tinnitus b. Polyuria c. Hyperglycemia d. Bradycardia 99. A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the following instructions should the nurse include in the teaching? a. “Remove yellow exudate around the penis” b. “Wrap sterile gauze around the penis if bleeding occurs” c. “Use soap to cleanse the site” d. “Apply petroleum jelly to the glans with diaper changes” 100. A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel? a. Remind the client to use the incentive spirometer b. Ask the client to describe her pain c. Observe the position of the suspended weight d. Check the client’s pedal pulse on the right leg 101. A nurse is assessing the growth and development of a 3-year-old child. Which of the following questions should the nurse ask the parent to determine if the child exhibiting typical developmental expectations? a. “Can your child catch and throw a small ball?” b. “Can your child ride a tricycle?” c. “Can your child name give colors?” d. “Can your child draw a stick figure?” 102. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Bradycardia b. Acrocyanosis c. Hypertonicity d. Bulging fontanels 103. A charge nurse is admitting four clients to an acute care unit. Which of the following clients should the nurse place near the nurses’ station? a. A client who is on fluid restriction b. A client who is in Buck’s traction c. A client who has orthostatic hypotension d. A client who has an open wound 104. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test? a. Serum potassium b. 12-lead ECG c. PT and INR d. Chest x-ray 105. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who has COPD and a respiratory rate of 44/min b. A client who has cancer with a sealed implant for radiation therapy c. A client who is receiving heparin for deep-vein thrombosis d. A client who is 1 day postoperative following a vertebroplasty 106. A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? a. Assess for skin necrosis b. Educate the family to avoid sharing personal belongings c. Ensure the state health department has been notified d. Administer antitoxin 107. A nurse is reviewing annual educational requirements for fire safety. Identify the sequence the nurse should use when operating a fire extinguisher. (move the steps of using a fire extinguisher in order) a. Point the hose at the base of the fire b. Sweep the extinguisher from side to side c. Squeeze the handles together d. Unlock the handle by pulling on the pin Pull , aim, squeeze, sweet PASS – Pull, point, squeeze, sweep 108. A nurse is caring for a client who has a nasogastric tube. Which of the following actions should the nurse take to verify tube placement prior to each feeding? a. Auscultate air insertion into the tube b. Test the bilirubin level of gastric contents c. Palpate the abdomen for tube placement d. Test the pH of gastric contents 109. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Perform Leopold maneuvers prior to auscultating the fetal heart rate b. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate c. Measure the fundal height to determine the placement of the ultrasound stethoscope d. Place the client in a side-lying position prior to assessing the fetal heart rate 110. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first? a. Ensure the device inspection sticker is current b. Report the defect to the equipment maintenance staff c. Remove the device from the room cc d. Initiate a requisition for replacement CPM device 111. A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take? a. Implement seizure precautions b. Monitor the client for hypoglycemia c. Perform range-of-motion exercises once per shift d. Place the client in high-Fowler’s position 112. A nurse is providing teaching to a client about the adverse effects sertraline. Which of the following adverse effects should the nurse include? a. Excessive sweating Yes diaphoresis b. Increased urinary frequency c. Dry cough d. Metallic taste in mouth 113. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? a. Contractions lasting 80 seconds- too long? b. FHR baseline 170/min normal 110-160 = c. Early decelerations in the FHR d. Temperature 37.4 C (99.3 F) 114. A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? a. Draw blood specimens for culture and sensitivity b. Administer nitroglycerin 0.4 mg SL 30 min before the procedure c. Transport the client to radiology for a CT scan d. Obtain a CBC with differential 115. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the followings actions should the nurse include in the plan? a. Ask the client directly what he is hearing b. Encourage the client to lie down in a quiet room c. Avoid eye contact with the client d. Refer to the hallucinations as if they are real 116. A nurse is reviewing the preadmission laboratory test results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? a. Sodium 142 mEq/L (normal) b. Potassium 3.3 mEq/L (Low)? c. Blood glucose 80 mg/dL (normal) d. PT 11.5 seconds (11-13.5) 117. A nurse is in the emergency department is caring for a client who has a new diagnosis of acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin. Which of the following findings should indicate to the nurse that the client is experiencing a satisfactory response to these interventions? a. The client’s stool is guaiac positive b. S3 heart sounds are present c. The client’s aPTT is two times the control d. Q wave is noted on the cardiac monitor tracing 118. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? a. “I understand the voices are frightening you, but I do not hear any voices” b. “Do you recognize the voices as belonging to anyone you know?” c. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself” d. “That can’t be true. The only voices in this room are yours and mine” 119. A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide? a. “Respite care includes volunteers who will perform household tasks” b. “Respite care provides clinicians to work with you in caring for your husband” c. “Respite care offers financial resources to help care for your husband” d. “Respite care allows for time away from caring for your husband” 120. A nurse working in the postpartum unit is reviewing a client’s new prescriptions for methylergonovine. The nurse should recognize that which of the world following is a contraindication for this medication? Treats severe bleeding after birth a. Hypertension b. Confusion c. Chlamydia d. Polyuria 121. A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? a. Decrease the maintenance infusion rate of IV fluid Xmore hypotension b. Have protamine sulfate available at the bedside- X Heparin c. Reposition the client side-to-side each hour d. Monitor the client hypertension X hypotension 122. A charge nurse observes a coworker who has impaired coordination and is drowsy while performing routine tasks. Which of the following actions should the charge nurse take first? a. Document observations about the nurse’s behavior b. Report the nurse’s behavior to the nurse manager c. Reassign the nurse’s client-care duties to another nurse CC d. Obtain support from another nurse before filing report 123. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has epidural analgesia and weakness in the lower extremities c. A client who has a hip fracture and a new onset of tachypnea d. A client who has diabetes mellitus and hemoglobin A1C of 6.8% 124. A nurse is caring for a client who has implanted venous access port. Which of the following should the nurse use to access the port? a. A noncoring needle- Huber point needle b. A butterfly needle c. An angiocatheter d. A 25-gauge needle 125. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who has leukemia and a platelet level of 95,000/mm3 (150-400) b. A client who has hepatitis B and total bilirubin of 1.2 mg/dL (0.1-1.0) c. A client who has diabetes mellitus and a HbA1c of 5.2% d. A client who received IV furosemide and has a serum potassium of 3.6 mEq/L 126. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should recognize that atrial fibrillation places the client at risk for which of the following conditions? a. Cardiac tamponade b. Pulmonary emboli c. Hemothorax d. Widened pulse pressure 127. A nurse is teaching about home care to the parents of an infant who has a tracheostomy. Which of the following instructions should the nurse include in the teaching? a. “Set the suction machine to 60 mm Hg” (no higher than 95 for infants) b. “Advance the suction catheter just past the point of resistance” c. “Instill 2 mL of saline in the tracheostomy prior to suctioning” d. “Apply suction for 30 seconds after advancing the catheter” (each suction attempt should be 5 seconds) 128. A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? a. “You don’t have to go through with the treatment” b. “It’s okay to be nervous before this treatment” c. “Most people who have this procedure feel better following the treatment” d. “Your doctor wouldn’t have ordered this treatment unless it was necessary” 129. A home health nurse is providing teaching about home safety to an older adult client. Which of the following statements by the client indicates that the teaching has been effective? a. “I put on socks when getting out of bed at night” (non- slip?) b. “I have marked the steps with black tape” (brighter color?) c. “I have grab bars next to my tub” d. “I have placed throw rugs in the hallways” X fall risk 130. A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching? a. “I should gargle with an alcohol-based mouthwash to kill germs” plain water b. “I should use a soft-bristle toothbrush to clean my teeth after meals” yes c. “I should limit my intake of dairy products to prevent nausea” d. “I should moisten my lips with lemon-glycerin swabs” lemon will irritate 131. A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client. Which of the following actions should the nurse take first? a. Check the compatibility of cefazolin with the client’s existing IV fluids b. Obtain the reconstituted antibiotic from pharmacy c. Review the client’s allergy history d. Assess the IV for patency 132. A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first? a. Review the child’s electronic pain diary b. Set up an appointment with the school nurse c. Refer the family to a chronic pain support group d. Request a change in medication from the provider 133. A nurse is providing teaching to a client who is receiving misoprostol for induction of labor. Which of the following information should the nurse include in the teaching? *nothing in the book or online, for abortion you insert, for induction you take orally a. “You will have intermittent fetal monitoring while you receive the medication” (intermittent??) b. “You will lie on your side for 30 minutes after the medication is inserted” (yes lie down for 30 minutes but only when aborting) c. “You will have a urinary catheter inserted prior to the placement of the medication” ( you should empty your bladder prior to insertion)- placement is for abortion, you get a cath when you are under epidural d. “You will have oxytocin initiated within 3 hours of administration of the medication” 134. A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse should document the finding as which of the following complications? a. Phlebitis b. Extravasation c. Circulatory overload d. Infiltration 135. A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal fever- tachycardia b. Fetal anemia c. Maternal hypoglycemia d. Chorioamnionitis- tachycardia 136. A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill? a. Doxorubicin hydrochloride- chemo drug it is hazardous b. Ampicillin sodium c. Metronidazole d. Phenytoin 137. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medication places the client at risk for delayed wound healing? a. Omeprazole b. Morphine c. Prednisone (steroid) d. Digoxin 138. A nurse is an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase? a. Hip arthroplasty 1 week ago b. Family history of malignant hypertension c. Chronic obstructive pulmonary disease d. Acute renal failure 6 months ago 139. A nurse is caring for a client who has permanent drooping on the left side of the face following a cerebrovascular accident (CVA). The client refuses to see any family members. Which of the following interventions will best assist the client to adapt to this body image change? a. Establish short-term goals that will enable the client to look in a mirror b. Offer contact information for CVA recovery support groups c. Initiate a family conference to address the issue d. Educate the client about short- and long-term effects of a CVA 140. A nurse is teaching the parent of an infant who hos positional plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? a. “I should avoid tummy time when my baby is wearing the helmet” b. “I should place my baby in the left side-lying position at night when using the helmet” c. “I should keep the helmet on my baby for 23 hours a day” (18-22 hours a day) d. “I should expect to have my baby wear this helmet for 10 months” 141. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? a. Remove the client’s restraints every 4 hr- its every 2 hours b. Document the client’s condition every 15 min c. Attach the restraint to the bed’s side rails d. Request a PRN restraint prescription for clients who are aggressive X 142. A nurse is assessing a client who has fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? a. Hyperparathyroidism b. Hyperthyroidism c. Hypoparathyroidism d. Hypothyroidism 143. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Leaving a nasogastric tube clamped after administering oral medication b. Documenting communication with a provider in the progress notes of the client’s medical record c. Administering potassium via IV bolus d. Placing a yellow bracelet on a client who is at risk for falls 144. A nurse in an acute care facility is caring for four clients. Which of the following clients should the nurse refer for speech therapy? a. A client who has dysphagia following a stroke b. A client who has sensorineural hearing loss c. An older adult client who has stage III Alzheimer’s disease d. A client who is postoperative following a tonsillectomy and adenoidectomy 145. A nurse is assessing client who has hypervolemia. Which of the following findings should the nurse expect? a. Bounding pulse b. Bradycardia c. Decreased blood pressure d. Urinary frequency 146. A nurse is assessing a client who is experiencing a pulmonary embolism. Which of the following manifestations should the nurse expect? a. Hypertension b. Frothy sputum c. Bradycardia d. Dyspnea 147. A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? a. Determine previous coping skills used by the client b. Establish the responsibilities of the nurse and client c. Facilitate the client’s problem-solving skills d. Assist the client in expressing alternative behaviors 148. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription of phenytoin. Which of the following instructions by the nurse is appropriate? a. “You should expect a change in the color of your stool while taking this medication” b. “Plan to take this medication with antacids”- not within 2-3 hours c. “Limit foods that contain folic acid while taking this medication” d. “Increase your intake of vitamin D while taking this medication” D 149. A nurse is caring for a group of clients. The nurse should recognize that which of the clients is at greatest risk for developing acute poststreptococcal glomerulonephritis? a. An 18-year-old girl who is in the second trimester of pregnancy b. A 16-year-old boy who has appendicitis c. A 2-month-old girl who has pyloric stenosis d. A 7-month-old boy who is recovering from impetigo- PSG develops after an infection caused by bacteria group A Strep. This includes strep throat and impetigo. CC 150. A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client? a. Peanut butter sandwich b. Oatmeal with butter c. Chicken noodle soup d. Celery sticks 151. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “I cannot be a witness for your consent to donate” b. “Your name cannot be removed once you are listed on the organ donor list” c. “Your desire to be an organ donor must be documented in writing” d. “You must be at least 21 years of age to become an organ donor” 152. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Place the client in seclusion b. Call the provider for discharge prescription c. Notify security to monitor the facility’s exits d. Inform the client of the risks involved if she leaves 153. A nurse is providing an in-service about the client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balance suspension traction b. A client who is bedridden and wears a hearing aid c. A client who uses a wheelchair and is confused d. A client who is ambulatory and receiving oxygen 154. A nurse is caring for a client who has Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? a. Schilling test (b12 deficiency test- determines ow well they are able to absorb) b. Thyroid scan c. Oral glucose tolerance test d. D-dimer test 155. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Increase intake of milk products – dairy c. Sweeten foods with fructose corn syrup d. Consume food high in bran fiber- high fiber 156. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching? a. “You will need blood work before and after the test” b. “You should avoid eating or drinking for 4 hours before the test” c. “You will have a Doppler transducer applied to your abdomen during the test” d. “You should massage one of your nipples to stimulate contractions of your uterus” 157. A nurse is creating a plan of care for a client who is postoperative following a coronary artery bypass graft (CABG). To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? a. Prepare for fluid volume replacement if the central venous pressure steadily increases b. Administer atropine to the client if tachycardia is present c. Maintain the indwelling urinary catheter until the client is ready for discharge d. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr – more than 150 is hemmorhage 158. A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take? a. Have provider evaluate the client in person within 1 hr- provider must assess within 1 hour b. Complete a written record regarding the seclusion and restraint every 2 hr? c. Plan to monitor the client every 30 min while restrained X Q2H d. Ensure that the prescription for restraints be renewed every 6 hr- renewed Q24H 159. A nurse is caring for a child who has just been admitted to the acute care medical unit. Which of the following laboratory findings should the nurse recognize as indicative of rheumatic fever? a. Decreased myoglobin and antinuclear antibody titer b. Decreased Hgb and platelet count c. Elevated creatine kinase and troponin- FOR MI d. Elevated sedimentation rate and C-reactive protein- esr measures inflammation. 160. A nurse is reviewing a client’s laboratory values. Which of the following should the nurse review to evaluate the client’s nutritional status? a. Erythrocyte sedimentation rate b. Troponin level c. Serum sodium d. Serum albumin 161. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Folate b. Zinc c. Iron d. Calcium 162. A nurse in an emergency department is receiving report for four clients. Which of the following clients should the nurse see first? a. A client who reports frequent and painful urination b. A client who reports left arm pain following a fall c. A client who has heart failure and received a diuretic 30 min ago d. A client who has hypertension and reports a severe headache -seizure or stroke 163. A nurse is reviewing the laboratory results of a client who has osteomyelitis and is receiving tobramycin. Which of the following findings indicate the client is experiencing an adverse effect of the medication? a. BUN 30 mg/dL b. Serum creatinine 0.4 mg/dL c. Albumin 3.2 g/dL d. Total bilirubin 0.08 mg/dL 164. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? Narcissistic worry about themselves, fantasies about their ultimate success, power, brilliance and beauty a. Ritualistic behavior- ocd b. Suspicious of others-schitzo c. Exhibits separation anxiety dependant d. Preoccupied with aging??? None of the others make sense with perfectionism 165. A mental health nurse is caring for a client who recently attempted suicide. The client states, “I wish I was dead.” Which of the following is an appropriate response by the nurse? a. “Did you take your medications today?” b. “Suicide is not the answer to your problems” c. “Don’t worry. Everything will be just fine” d. “You seem like you’re feeling hopeless” 166. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? a. A client who received a Mantoux test 48 hr ago and has an induration (could be positive for TB, when you have an induration is has to be measured and they should probably have a blood test or chest xray to confirm TB?) b. A client who is scheduled for a colonoscopy and is taking sodium phosphate X fine it is a bowel cleanser c. A client who is taking warfarin and has an INR of 1.8 (Therapeutic 2.0-3.0) Low INR means blood is coagulating and risk for developing a clot, maybe compared to TB this isn’t too bad??? d. A client who is taking 3 and has a potassium level 3.6 mEq/L X fine 167. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? a. Secure the drain to the bedding b. Position the affected extremity below the level of the client’s heart c. Maintain the client in supine position for the first 24 hr d. Reset the vacuum by compressing the container 168. A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply) a. Assess the client’s lung sounds prior to the infusion b. Prime the infusion tubing with 0.45% sodium chloride (0.9% ONLY) c. Don sterile gloves to prepare the blood administration setup (I think just clean gloves should be fine, never heard sterile- it just says maintain a sterile technique during the transfusion but not the set up) d. Infuse the blood over 4 hr e. Verify with another nurse that the unit of blood is compatible with the client’s blood type 169. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take? (Select all that apply) a. Change gloves after contact with infectious material b. Wear a gown when providing care c. Wash hands with an alcohol-based cleaner- wash hands with soap and water d. Remove the thermometer from client’s room for use on another client – leave the stuff in the room for each patient e. Wear an N95 respirator when providing care- this is only for airborne precautions 170. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Schedule a time for the home visit b. Implement the nursing process c. Clarify the source of the referral d. Contact the family by phone 171. A nurse in a maternal newborn unit is admitting a client who is in labor and at 38 weeks of gestation. The client has a history of herpes simplex virus 2. Which of the following questions is most important for the nurse to ask the client? a. “Do you have an active lesion?” b. “Are you currently taking acyclovir?” c. “When did your labor begin?” d. “How long ago were you first diagnosed?” 172. A nurse is caring for a 3-day-old newborn who has a congenital heart defect. Which of the following interventions should the nurse include to decrease cardiac demands for the newborn? * must conserve the child’s energy, frequent rest periods, cluster care, small frequent meals, a. Encourage the infant’s parents to limit visitation and physical touch *I’m sure parents visiting soothes the baby b. Maintain the infant’s temperature at 37 C (98.6 F) *doesn’t say anything about temp, plus the normal infant temp is 97.7- 98.9 c. Keep the infant’s bed in a flat position X *maintain semi-flower’s when awake d. Feed the infant when she is awake and crying *keep crying to a minimum also, allow the infant to rest during feedings