1. A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the following findings as an indication of a possible allergic reaction to the medication?
A. Bradycardia
B. Headache
...
1. A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the following findings as an indication of a possible allergic reaction to the medication?
A. Bradycardia
B. Headache
C. Joint pain
D. Hypotension
2. A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing auditory hallucinations telling them to hurt others. The client is refusing to take anti-psychotic medication. Which of the following responses should the nurse make?
A. “You should plan to take this medication for a few weeks.”
B. “You will regret it if you do not take this medication.”
C. “This medication will help you respond to the voices.
D. “This medication will help you stop the voices you are hearing.”
3. A nurse is providing care for a patient who has depression and is to have electroconvulsive therapy. Which of the following conditions should the nurse identify as increasing the client’s risk for complications?
A. Hyperthyroidism
B. Renal calculi
C. Diabetes mellitus
D. Cardiac dysrhythmias
4. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider?
A. WBC count 8,000/mm
B. Platelets 150,000/mm
C. Aspartate aminotransferase 10 units/L D. Erythrocyte sedimentation 75 mm/hr
5. A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that suctioning has been effective?
A. Presence of a productive cough
B. Decreased peak inspiratory pressure
C. Thinning of mucous secretions
D. Flattening of the artificial airway cuff
6. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
A. Stand within 30cm (1 ft) of the client when speaking with them.
B. Express sympathy for the client’s situation.
C. Confront the client about his behavior. D. Speak assertively to the client.
7. A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing’s disease. Which of the following actions is the nurse’s priority?
A. Reposition the client for comfort every 2 hours
B. Observe for any indications of infection
C. Document amount and color of the incisional drainage. D. Monitor the client’s fluid and electrolyte status.
8. A nurse is caring for a client who is scheduled for a surgical procedure and states, “I don’t want to have this surgery anymore.” Which of the following responses should the nurse make?
A. “We can manage your care following the procedure without complications.” B. “You have the right to refuse the procedure.”
C. “Your doctor thinks the surgery is necessary.”
D. “Let me review the procedure so you can understand what is going to happen.”
9. A nurse is evaluating a client who has borderline personality disorder. Which of the following behaviors indicates an improvement in the client’s condition?
A. Impulsive behaviors
B. Decreased clinging behavior
C. Liability of mood
D. Dependent behavior
10. A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
A. Air-popped popcorn
B. Milkshake made with whole milk.
C. Baked potato chips
D. Cheesecake
11. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium
B. Ibuprofen
C. Acetaminophen
D. Aspirin
12. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse plan to administer?
A. Colchicine
B. Lorazepam C. Pregabalin
D. Codeine
13. A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. Which of the following laboratory values indicates that the client is at risk for developing digoxin toxicity?
A. Glucose 150 mg/dL
B. Magnesium 1.3 mEq/L C. Potassium 3.1 mEq/L
D. Sodium 134 mEq/L
14. A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of the following in the client’s history should the nurse identify as a contraindication for receiving alteplase?
A. Hip arthroplasty 1 week ago correct
B. Obstructive lungs disease
C. Retinal detachment
D. Acute kidney failure 6 months ago
15. A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?
A. “I will soak in the tub rather than showering.”
B. “I can hold my cellphone on the same side of my body as the ICD.” C. “I will wear loose clothing over my ICD.”
D. “I will avoid using my microwave oven at home because of my ICD.”
16. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions should the nurse anticipate?
A. Clamp the catheter tubing for 30 min
B. Initiate continuous bladder irrigation
C. Obtain a urine specimen for culture and sensitivity
D. Administer a fluid bolus
17. A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?
A. Avoid talking to the client about the newborn
B. Discourage the client from allowing friends to see the newborn C. Offer to take pictures of the newborn for the client
D. Assure the client that she can have additional children
18. A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse’s priority to prevent wound infection?
A. Use sterile dressings for wound care
B. Apply topical antibiotics to the client’s wounds.
C. Place the client in protective isolation.
D. Maintain consistent hand washing by staff.
19. A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states, “Providing constant care is very stressful and is affecting all areas of my life.” Which of the following actions should the nurse take?
A. Discuss methods of how to communicate with the client about problem solving behaviors.
B. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client. C. Assist the caregiver to arrange a daycare program for the client.
D. Recommend allowing the client to have time alone in their room throughout the day.
20. A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?
A. Administer a benzodiazepine
B. Perform a fundal massage
C. Place an ice pack on the client’s perineum D. Place the client’s hand in warm water
21. A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
A. Compare a list of common medications to treat a condition to the actual prescriptions
B. Compare the prescription to the allergy history of the client
C. Compare the medication label to the provider’s prescription on three occasions before administration
D. Compare the client’s list of home medications to the admission prescriptions written for the client.
22. A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has preterm labor. Which of the following findings should the nurse identify as an adverse effect of this medication?
A. Hyperglycemia
B. Uterine contractions
C. Proteinuria
D. Hypotension
23. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (SATA)
A. Apply a tourniquet above the catheter insertion site.
B. Access the catheter using a large bore needle.
C. Aspirate for blood return to access catheter patency.
D. Flush the catheter with 0.9% sodium chloride.
E. Apply force when resistance is met while flushing the catheter.
24. A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?
A. Explain in simple terms how the procedure will affect the child.
B. Ask the parents to wait outside the room during the procedure.
C. Limit teaching sessions about the procedure to 20 min.
D. Instruct the child in deep-breathing methods prior to the procedure.
25. A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?
A. Irrigate the wound using a 10-mL syringe.
B. Cleanse the wound starting at the bottom and moving upward.
C. Cleanse the insertion site of the drain using a circular motion towards the center. D. Irrigate the wound with a low-pressure flow of solution.
26. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A. A client who is at 36 weeks of gestation and has a biophysical profile score of 8. B. A client who has preeclampsia and reports a persistent headache.
C. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%.
D. A client who is at 28 weeks of gestation and reports leukorrhea.
27. A nurse is caring for a client who is recovering from an amputation of her right arm above the elbow. Which of the following information should the nurse report the occupational therapist?
A. The client’s parent is in a skilled nursing facility. B. The client has two small children at home.
C. The client is allergic to penicillin.
D. The client lives in a two-story home.
28. A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone.” Which of the following responses should the nurse make?
A. “You should join a community support group.”
B. “What makes you think that?”
C. “Don’t worry. You should be feeling better in a couple weeks.”
D. “Can you give me an example of how others are making you feel this way?”
29. A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?
A. Prepare for a CT scan.
B. Insert a peripheral IV line. C. Establish a patent airway.
D. Apply direct pressure to the nose.
30. A nurse is reviewing the rhythm strip of a client who is experiencing sinus arrhythmia. Which of the following findings should the nurse expect?
A. Inconsistent P wave formation.
B. Ventricular and atrial rates 120/min
C. P-R intervals of 0.30 seconds
D. P to QRS ratio 1:1 page 720 Med surg book
31. A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
A. Confabulation
B. Agnosia
C. Projection
D. Perseveration
32. A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?
A. Place a handrail in the entryway of the house.
B. Place a towel on the floor outside of the shower.
C. Ensure that all area rugs are rubber-backed.
D. Wear slippers with cloth soles.
33. A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
A. Raise the head of the client’s bed to a high-fowler’s position.
B. Elevate the client’s effected leg on a pillow when in bed.
C. Position the client’s knees slightly higher than the hips when up in a chair. D. Keep an abduction pillow between the client’s legs.
34. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster virus. Which of the following information should the nurse include?
A. Children who have varicella should be placed on droplet precautions.
B. Children who have varicella are contagious 4 days before the first vesicle eruption. C. Children who have varicella are contagious until the vesicles are crusted.
D. Children who have varicella should receive the herpes zoster vaccine.
35. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Teach the client how to meditate
B. Sit with the client to provide a sense of security.
C. Encourage the client to watch television.
D. Administer a dose of atomoxetine to decrease anxiety.
36. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?
A. Stands with feet together when lifting a client up in bed.
B. Places a gait belt around the client’s upper chest before assisting a client to stand. C. Uses a mechanical lif t device to move a client from the bed to the chair.
D. Raises the client’s head of the bed before pulling the client up.
37. A nurse is teaching a client about condom use. Which of the following client statements should the nurse identify as an understanding of the teaching?
A. “I can use petroleum jelly as a lubricant with the condom.”
B. “I can re-use the condom one time after initial use.”
C. “I can use natural-skin condoms to prevent sexually transmitted infections.” D. “I can store the condoms in the drawer of my night-stand.”
38. A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (SATA)
A. Maintain the collection chamber above the level of the client’s waist. B. Mark the drainage output on the collection chamber hourly.
C. Clamp the chest tube every 2 hours to assess the amount of drainage. D. Add water to the water seal chamber as it evaporates.
E. Strip the chest tube vigorously to dislodge blood clots.
39. The nurse is reviewing a medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication to heat therapy?
A. Osteoarthritis
B. Peripheral neuropathy
C. Abdominal aortic aneurysm
D. Phlebitis
40. A charge nurse is recommending postpartum clients for discharge following a local disaster. Which of the following client’s should the nurse recommend for discharge first?
A. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
B. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
C. A client who delivered precipitously and has a second-degree perineal laceration
D. A client who has received 2 units of RBCs 6 hr ago for a postpartum hemorrhage
41. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching?
A. The client flexes her elbows 10 degrees when supporting weight by using the handgrips. ATI page 222 Fundy. IT HAS TO BE 30 DEGREE
B. The client places the crutches 30 cm (12 in) to the front and side of each foot while standing
C. The client leans on both crutches to support body weight. D. The client keeps her axillae free of pressure.
42. A nurse is preparing the body of a client who has died for the family to view. Which of the following actions should the nurse take?
A. Place a pillow under the client’s head.
B. Remove the client’s dentures.
C. Remove the client’s identification tags.
D. Place the client’s arms across their chest.
43. A nurse is reviewing annual education requirements for fire safety. Identify the sequence that the nurse should use when operating a fire extinguisher.
1. Unlock the handle by pulling on the pin. 2. Point the hose at the base of the fire.
3. Squeeze the handles together.
4. Sweep the extinguisher from side to side.
44. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make?
A. Ensure that the client has a living will on file prior to treatment.
B. Place copies of incident reports in the clients’ medical records.
C. Obtain personal professional liability insurance coverage.
D. Overestimate the clients’ acuity to prevent short staffing.
45. A nurse is caring for a client who speaks a language different than the nurse. Which of the following actions should the nurse make?
A. Review the facility policy about the use of an interpreter.
B. Direct attention toward the interpreter when speaking to the client.
C. Request a family member or friend to interpret information to the client.
D. Request an interpreter of a different sex from the client.
46. A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following findings should the nurse identify as a manifestation of hypovolemic shock?
A. Decreased respiratory rate
B. Change in level of consciousness
C. Increased urine output
D. Hyperactive deep-tendon reflexes
47. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
A. Position the casted extremity on a pillow.
B. Place an ice pack over the cast.
C. Teach the client to keep the cast clean and dry. D. Palpate the pulse distal to the cast.
48. A nurse is performing a gait assessment on a client to evaluate the client’s ability to perform ADLs. Which of the following findings indicates a standard gait?
A. The client looks at the floor when walking.
B. The client’s shoulders are rounded slightly forward. C. The client’s heels touch the ground before their toes.
D. The client’s dominant foot bears more weight.
49. A nurse on a mental health unit is caring for a client who has suicidal ideation. Which of the following actions should the nurse take?
A. Place the client in a group therapy session.
B. Avoid discussing suicidal thoughts with the client.
C. Give the client a radio to listen to in his room. D. Establish a no-suicide contract with the client.
50. A nurse is providing teaching about nutrition therapy to a client who is experiencing anorexia due to chemotherapy treatment. Which of the following statements should the nurse make?
A. “Snack frequently on fresh fruit.”
B. “Add water to soups to increase volume.”
C. “Avoid adding butter to foods.”
D. “Add grated cheese to vegetable dishes.”
51. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about administering NPH and regular insulin together in one injection. Which of the following instructions should the nurse include?
A. Inject into the vastus lateralis.
B. Draw up the regular insulin prior to NPH.
C. Use a 15-degree angle for the injection.
D. Roll the syringe gently to ensure mixture of the insulins.
52. A nurse is caring for a client who has a calcium level of 8 mg/dL. Which of the following actions should the nurse take?
A. Request a prescription for magnesium citrate.
B. Request a prescription for furosemide.
C. Place the client on a low-calcium diet. D. Place the client on seizure precautions.
53. A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the following actions should the nurse take?
A. Encourage the client to rest quietly in bed twice per day.
B. Direct long conversations about the delusions toward reality-based topics.
C. Allow the client unlimited time to discuss the delusions when they occur.
D. Avoid assessing the client’s delusions.
54. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?
A. Asthma
B. Fibromyalgia C. Hypertension
D. Fibrocystic breast condition
55. A nurse in the emergency department is triaging victims of a house fire. Which of the following clients should the nurse prioritize as emergent?
A. Client who has a compound fracture of the femur B. Client who has hypertension and reports chest pain
C. Client who has severe abdominal pain
D. Client who has a deep laceration on both thighs
56. A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively?
A. Gather supplies prior to completing a dressing change.
B. Complete partial assessments on all clients before planning the day.
C. Prioritize activities based on the nurse’s needs.
D. Use break time to perform documentation.
57. A nurse on a mental health unit is planning room assignments for four clients. Which of the following clients should the nurse assign to room near the nurse’s station?
A. A client who has a somatic symptom disorder and reports chronic pain.
B. A client who has an anxiety disorder and is experiencing moderate anxiety.
C. A client who has bipolar disorder and impaired social interactions. D. A client who has a depressive disorder and reports feeling hopeless.
58. A nurse is assessing coping strategies of a client whose partner has alcohol use disorder. Which of the following findings indicates that the client is coping effectively?
A. The client utilizes strategies to enhance codependent behaviors. B. The client attends regular counseling sessions.
C. The client exhibits sympathy to the partner.
D. The client ignores the partner when they are using alcohol.
59. A nurse is caring for a client who has Graves’ disease and is experiencing a thyroid storm. Which of the following actions is the nurse’s priority?
A. Obtain the client’s blood glucose.
B. Administer 0.9% sodium chloride IV. C. Provide a cooling blanket.
D. Monitor the client’s cardiac rhythm. This has more priority
60. A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
A. “Remain on bed rest for 24 hours following the procedure.”
B. “Use an incentive spirometer every 4 hours.” C. “Participate in range-of-motion exercises.”
D. “Place a pillow under your knees while in bed.”
61. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse when pouring the sterile solution?
A. Hold the bottle in the center of the sterile field when pouring the solution.
B. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
C. Place the sterile gauze over areas of spilled solution within the sterile field. D. Remove the cap and place it sterile-side up on a clean surface.
62. A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the back of the legs of one of the children. Which of the following actions should the nurse take first?
A. Contact child protective services.
B. Refer the parents to a self-help group.
C. Instruct the parents about methods of discipline.
D. Document clinical findings.
63. A nurse is teaching a client who is to undergo placement of a non-tunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching? A. “The provider will wear a mask while performing the procedure.”
B. “You should not eat or drink for 4 hours prior to the procedure.”
C. “Your head will be elevated as high as possible while the catheter is inserted.”
D. “The provider will give you pain medication before inserting the catheter.”
64. A nurse in a clinic is reviewing the health history of a client during her first prenatal visit. Which of the following findings indicates a risk for gestational diabetes mellitus?
A. 1-hr glucose tolerance test if 128 mg/dL
B. Previous miscarriage
C. Delivery of a low birth-weight infant D. BMI of 31
65. A nurse is caring for a client who is incontinent and has a stage II pressure injury on their coccyx. Which of the following interventions should the nurse implement?
A. Apply lotion to the skin every 4 hr.
B. Reposition the client every 3 hr.
C. Position the client laterally at 30 degrees.
D. Have two facility personnel help to slide the client up in bed.
66. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as the clinic staff. Which of the following instructions should the nurse include?
A. Offer clients translation services for a nominal fee.
B. Use clients’ children to provide interpretation.
C. Evaluate clients’ understanding at regular intervals.
D. Direct questions to a medical interpreter.
67. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to provide cost-effective care?
A. Leave the unused infusion pump in the room until discharge. B. Bring in formula as needed.
C. Return unopened equipment to the supply center.
D. Stock the room with a 2-day supply of disposable diapers.
68. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the following prescriptions should the nurse expect the provider to prescribe?
A. Interferon beta-1a
B. Enoxaparin
C. Atorvastatin
D. Amoxicillin
69. A nurse is speaking with the partner of a client who is in the early stage of Alzheimer’s disease. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to
leave him home alone while she travels for work. Which of the following referrals should the nurse make?
A. Respite care
B. Restorative care
C. Hospice
D. Rehabilitation facility
70. A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?
A. Orthostatic hypotension
B. Decreased respirations
C. Polyuria
D. Bradycardia
71. A nurse is caring for a client who is at 14 weeks of gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
A. “When did you start having these feelings?”
B. “Have you discussed these feelings with your partner?”
C. “You should discuss your feelings about being pregnant with your provider.” D. “Describe your feelings to me about being pregnant.”
72. A nurse manager is planning to promote client advocacy among staff on a medical unit. Which of the following actions should the nurse plan to take?
A. Instruct unit staff to share personal experiences to help clients make decisions.
B. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice.
C. Develop a system for staff members to report safety concerns in the client care environment.
D. Tell staff to explain procedures to clients before obtaining informed consent.
73. A nurse received a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide for the parent?
A. “Place a warm, wet washcloth over your child’s forehead and the bridge of their nose.”
B. “Tell your child to blow their nose gently, and then sit down and tilt their head backward.”
C. “Use your thumb and forefinger to apply pressure to the sides of your child’s nose.”
D. “Have your child lie down and turn their head to the side for 10 minutes.”
74. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care?
A. Hgb 15 g/dL.
B. Appearance of pink tissue under eschar.
C. Albumin level 4.0 g/dL
D. Weight loss of 5% in 10 days.
75. A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?
A. Inspection B. Palpation
C. Auscultation
D. Percussion
B. and aspirate in the NG tube.
76. A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client’s condition is improving?
A. The client avoids eye contact with others.
B. The client exhibits a flat affect.
C. The client participates in self-care.
D. The client experiences self-doubt when making decisions.
77. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next?
A. Provide the client with an instructional handout about swallowing exercises.
B. Ask a speech therapist to evaluate the client’s ability to swallow.
C. Discuss the manifestations of impaired swallowing with the AP.
D. Listen to the client’s lung sounds.
78. A nurse in an acute mental health facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A. A client who has obsessive-compulsive disorder and is upset about change in daily routine
B. A client who has depressive disorder and requires assistance with ADLs
C. A client who has narcissistic personality disorder and is mocking others during group therapy
D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
79. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel (AP). Which of the following statements should the nurse include in the teaching? A. “The RN evaluates client needs to determine tasks to delegate.”
B. “An AP can perform tasks outside of his range of function if he has been trained.”
C. “An experienced AP can delegate tasks to another AP.”
D. “The RN is legally responsible for the actions of the AP.”
80. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?
A. Memory loss
B. Hypotension
C. Elevated temperature
D. Slurred speech
81. A nurse administered 400mg of ibuprofen to a client 2 hr ago to treat pain following a biopsy. The client is crying and states, “It really still hurts a lot.” Which of the following actions should the nurse take?
A. Administer an additional dose of ibuprofen to the client.
B. Request a prescription for an opioid pain medication for the client.
C. Report this client finding to the provider.
D. Ask the client to rate their pain on a scale of 0 to 10.
82. A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (SATA)
A. Allow the client to choose among a variety of activities each day.
B. Refute the client’s delusions using logic.
C. Establish eye contact when communicating with the client. D. Reinforce orientation to time, place, and person.
E. Give the client one simple direction at a time.
83. A nurse is providing nutritional teaching to a client who is experiencing severe nausea. Which of the following responses by the client indicates an understanding of the teaching?
A. “I should increase my intake of liquids with meals.” B. “I should focus on eating complex carbohydrates.”
C. “I should lie down after my meals.”
D. “I should sip on clear carbonated beverages that have gone flat.”
84. A nurse is providing teaching about disulfiram to a client who has alcohol use disorder. Which of the following statements should the nurse make?
A. “Wait at least 12 hr after your last drink to take this medication.”
B. “Alcohol should not be consumed for 3 days following your last dose.”
C. “This medication will decrease your risk for delirium during your withdrawal from alcohol.”
D. “This medication will prevent seizures during your withdrawal from alcohol.”
85. A nurse is assessing a client following an ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?
A. The client reports a metallic taste in his mouth.
B. The client has poor-fitting dentures.
C. The client reports a decreased appetite. D. The client coughs after swallowing.
86. A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?
A. Limit the client’s opportunities to socialize with others.
B. Mix the medication with the client’s food items.
C. Rotate staff members caring for the client.
D. Speak in a neutral tone when addressing the client.
87. A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
A. Report of discomfort at the insertion site. B. Hematoma over the insertion site.
C.
D. Bounding pulses in the affected extremity.
E. Heart rate 90/min
88. A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?
A. Have the client store smaller tanks under his bed.
B. Place the oxygen tank away from curtains or drapes.
C. Ensure that the client checks the gauge weekly.
D. Store the oxygen tank wrench in a locked cabinet.
89. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching.
A. “I don’t need to use a walker when walking around my house.”
B. “I will start my leg exercises 3 days after returning home.” C. “I won’t cross my legs when sitting in a chair.”
D. “I will bend at the hips when tying my shoes.”
90. A nurse is teaching a client about the oral administration of chlorpromazine. Which of the following information should the nurse include?
A. Move slowly when standing from a sitting position.
B. Expect loose stools as an adverse effect.
C. Anticipate an increase in saliva production.
D. Monitor for an increase in the occurrence of hiccups.
91. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?
A. Assess the fetal heart rate. B. Discontinue the infusion.
C. Administer calcium gluconate.
D. Obtain the client’s magnesium level.
92. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following findings should the nurse report to the provider?
A. BUN mg/dL
B. Urine specific gravity 1.023 C. Serum creatinine 1.6 mg/dL
D. Urine pH 6.2
93. A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?
A. Allow the client to walk unassisted near the nursing station. B. Establish an elimination schedule for the client.
C. Silence the bed alarm when visitors are at the client’s bedside.
D. Raise all four bed rails on the client’s bed.
94. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?
A. Asks security to detain the client until the provider is notified.
B. Asks the client what her plans are for follow-up care.
C. Shows the client her abnormal laboratory results.
D. Asks the client to sign a form releasing the hospital from legal responsibility.
95. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following nursing interventions should the nurse include in the plan of care for this client?
A. Flush IV tubing with hypotonic solution.
B. Encourage oral hydration of 1,800mL daily C. Perform neurologic checks.
D. Weigh the client weekly.
96. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?
A. Check the cords of the IV pump for fraying.
B. Grasp the IV pump cord when unplugging it from the electrical outlet.
C. Remove the safety inspection sticker before plugging in the IV pump.
D. Ensure that the electric outlet has two prongs for the IV pump.
97. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?
A. Nurses should discontinue the critical pathway if variances occur.
B. Nurses’ notes are used to create the critical pathway.
C. Critical pathways should reduce health care costs.
D. Critical pathways have an unlimited timeframe for completion.
98. A nurse is providing teaching to a client who has otitis media and is 1 hr postoperative following a myringotomy. Which of the following statements should the nurse include in the teaching?
A. “You should not drink through a straw for 2 weeks.”
B. “You can wash your hair 3 days after the procedure.”
C. “You should blow your nose with your mouth closed.”
D. “You should expect excessive ear drainage for about 48 hours.”
99. A nurse is teaching a newly licensed nurse about incidents reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “They assist with unit quality improvement.”
B. “They are used as a disciplinary tool for nurse evaluations.”
C. “They assist the facility to achieve benchmark goals.”
D. “They are mandatory government documentation.”
100. A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
A. Decrease socialization with extended relatives until roles are identified.
B. Encourage authoritative communication from the adult child.
C. Minimize open discussion regarding the changes to avoid embarrassment. D. Implement firm but flexible boundaries in their relationship.
101. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of care?
A. Ask the client to shift his weight every 20 min while sitting in a chair.
B. Massage reddened areas over bony prominences.
C. Maintain the head of the bed at a 45-degree angle.
D. Provide a high-fiber diet for the client.
102. A nurse in a provider’s office is reviewing the laboratory results of group clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
A. Chlamydia
B. Candidiasis
C. Herpes simplex virus
D. Human papillomavirus.
103. A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?
A. “You should avoid vaginal spermicides while breastfeeding.”
B. “The lactation amenorrhea method is effective for your first year postpartum.” C. “Place the transdermal birth control patch on your upper outer arm.”
D. “You can continue to use the diaphragm you used before your pregnancy.”
104. A nurse is caring for a client who is 12 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
A. Burgundy-colored urine
B. Report of pain level 5 on a scale of 0 to 10.
C. Passage of small clots.
D. Urgency to void.
105. A nurse is caring for a client who is receiving enteral feedings through a nasoenteric tube and has aspirated fluid prior to feeding. Which of the following findings should indicate to the nurse that the tube is positioned in the client’s lung?
A. Residual fluid with a pH of 1 B. Residual fluid with a pH of 8
C. Residual fluid with a pH of 6
D. Residual fluid with a pH of 3
106. A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure?
A. Trendelenburg
B. Prone
C. Right lateral
D. High-fowler’s
107. A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
A. Keep visitors at least 6 feet (1.8 m) away from the client.
B. Place the client’s soiled bed linens in a biohazard bag outside the client’s room.
C. Wear an isolation gown when caring for the client.
D. Discard the radioactive source in the client’s trash can.
108. A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority consult?
A. Speech-language pathologist
B. Dietitian
C. Occupational therapist
D. Physical therapist
109. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the entries should the nurse make in the medical record?
A. “Morphine 3 mg SC q 4 hr PRN for pain.”
B. “Morphine 3 mg SQ every 4 hr PRN for pain.”
C. “Morphine 3 mg subcutaneous every 4 hr PRN for pain.”
D. “Morphine 3.0 mg sub q every 4 hr PRN for pain.”
110. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
A. Wear sterile gloves to collect the specimen from the client.
B. Obtain the specimen immediately upon the client waking up.
C. Wait 1 day to collect the specimen if the client cannot provide sputum.
D. Ask the client to provide 15 to 20 mL of sputum into the container.
111. A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching? A. “I will place a ticking clock nearby to soothe my baby throughout the day.”
B. “I can use a firm pillow to prop up the bottle when feeding my baby.”
C. “I will avoid picking up my baby too often to keep from spoiling him.”
D. “I will hang a pastel-colored mobile 24 inches above my baby’s crib.”
112. A nurse is planning care for a client who has COPD and weight loss. Which of the following interventions should the nurse include in the plan?
A. Schedule a large meal in the evening.
B. Provide high-protein nutritional supplements.
C. Offer hot fluids along with meals.
D. Encourage the client to eat toast for breakfast.
113. A nurse is providing teaching to an older client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include?
A. “Limit foods that contain vitamin D while taking this medication.” B. “Plan to take this medication with food.”
C. “Limit foods that contain folic acid while taking this medication.”
D. “Plan to take this medication with antacids.”
114. A nurse is reviewing the facility’s safety protocols concerning newborn abduction with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching?”
A. “I will not publish a public announcement about my baby’s birth.”
B. “Staff will apply identification bands to my baby after her first bath.”
C. “I can leave my baby in my room while I walk in the hallway.”
D. “I can remove my baby’s identification band as long as she is in my room.”
115. 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 the following screening tests at 16 weeks of gestation?
A. Cervical cultures for chlamydia
B. Chorionic villus sampling
C. Maternal serum alpha-fetoprotein
D. Nonstress test
116. A nurse is providing nutritional teaching about appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following foods should the nurse include in the teaching?
A. Liver
B. Roast beef
C. Chicken
D. Lima beans
117. A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?
A. Use short sentences when communicating with the client.
B. Have the client journal about what is happening to him.
C. Tell the client to sit alone in a private place and reflect on the situation.
D. Encourage the client to talk about his feelings.
118. A nurse is teaching a client about advance directives. Which of the following statements should the nurse make?
A. “A family member will need to cosign the advance directives document.”
B. “An attorney will need to review your advance directives.”
C. “Advance directives can include a do-not-resuscitate order signed by the provider.”
D. “A health care surrogate will handle your medical bills.”
119. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
A. Sneezing
B. Substernal retractions
C. Temperature 37.9 degrees (100.2 F)
D. Hematuria
120. A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect?
A. Paradoxical chest movement
B. Bilateral crackles
C. Asymmetry of the chest
D. Blood-tinged sputum
121. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunizations should the nurse recommend?
A. Human papillomavirus B. Influenza
C. Measles, mumps and rubella
D. Varicella
122. A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child. Which of the following findings should the nurse report to the provider?
A. Hct 40%
B. Hgb 12.5 g/dL
C. Platelets 250,000/mm D. WBC 14,000/mm
123. A nurse is assessing a client who is receiving packed RBCs. Which of the following indicates fluid overload?
A. Low-back pain
B. Thready pulse
C. Hypotension D. Dyspnea
124. A nurse is caring for an adult client who asks about risk factors for Alzheimer’s disease. Which of the following responses should the nurse take?
A. “There are no known genetic mutations that cause Alzheimer’s disease.”
B. “A diet low in carbohydrates increases the risk for Alzheimer’s disease.”
C. “Asthma has been identified as a risk factor for Alzheimer’s disease.”
D. “Repeated concussions increase the risk for Alzheimer’s disease.”
125. A community health nurse is developing a plan to improve the community’s environmental health. Which of the following actions should the nurse take first? A. Collect information about the community’s environmental status.
B. Request funding from community organizations.
C. Establish a timeframe for environmental improvements.
D. Encourage community involvement in the environmental improvement.
126. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following information should the nurse include about preventing the spread of infection?
A. Use condoms with petroleum-based lubricant.
B. Buy disposable dishes for daily use.
C. Clean blood-contaminated surfaces with bleach.
D. Wash soiled clothes in cold water.
127. A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
A. Avoid preparing medications for more than two clients at one time.
B. Inform clients about the action of the medication of the medication prior to administration.
C. Read medication labels at least two times prior to administration.
D. Complete an incident report if a client vomits after taking a medication.
128. PICTURE – SECOND BABY (B)
129. A nurse in a pediatric clinic is assessing a 6-month old infant. Which of the following findings should the nurse identify as a possible indication of neglect?
A. Inability to sit without support.
B. A capillary hemangioma on the buttocks.
C. Current weight twice the infants birth weight. D. Lack of social smile.
130. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the disease, the nurse should identify which of the following electronic databases has the most comprehensive collection of nursing journal articles?
A. MEDLINE B. CINAHL
C. Health science
D. ProQuest
131. A nurse in a provider’s office is assessing a client for melanoma. Which of the following findings should the nurse report to the provider?
A. Red, pustular lesions on the face
B. Circular, brown plaques on the arms
C. Round, light tan pigmented spots on the face
D. Red-blue papule on the upper back
132. A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?
A. Restlessness
B. Mottled skin
C. Constricted pupils
D. Cheyne-stokes respirations
133. A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?
A. Oral
B. Axillary
C. Tympanic
D. Rectal
134. A nurse is preparing to administer vancomycin IV to a client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
A. “I can start the medication 30 minutes earlier.”
B. “I have up to 2 hours after the usual schedule time to give you this medication.”
C. “I can infuse the medication at a faster rate.”
D. “I can adjust the time and schedule for when it’s convenient for you.”
135. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse take?
A. Elevate the client’s arm prior to insertion.
B. Select a site on the client’s dominant arm.
C. Apply a tourniquet below the venipuncture site. D. Choose a vein that is palpable and straight.
136. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemisphere stroke. Which of the following interventions should the nurse include in the plan?
A. Place the client’s lef t arm on a pillow while he is sitting.
B. Maintain the client on bed rest.
C. Provide total care in performing the client’s ADLs.
D. Place food on the left side of the client’s mouth when he is ready to eat.
137. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of the steps the nurse manager should plan to take in response to the staff member’s conduct. (Move steps into the box on to the right, placing them in order of performance. Use all steps.)
1. Verbally remind the staff member of the expected behavior changes. 2. Give the staf f member a written warning about the behavior.
3. Set up a meeting to speak with the staff member about the behavior. 4. Suspend the staff member from work for several days.
5. Dismiss the staff member from employment at the facility.
138. A nurse is teaching a client who has chronic urinary tract infections. Which of the following instructions should the nurse include?
A. Take tub baths instead of showers
B. Wipe from back to front after a bowel movement.
C. Drink at least 1 L of fluid every day. D. Try to void every 4 hr.
139. A nurse is caring for a newly admitted client who has a history of expressive aphasia. Which of the following actions should the nurse take?
A. Speak loudly when facing the client.
B. Apply a safety monitoring device on the client’s bed.
C. Use a picture board to communicate with the client.
D. Provide the client with an artificial voice box.
140. A nurse in a long-term care facility is caring for a client who has Alzheimer’s disease. The client’s partner asks why the client started taking memantine instead of donepezil. Which of the following responses should the nurse make?
A. “Memantine improves cognitive function in later stages of Alzheimer’s.”
B. “Memantine helps prevent seizures in clients who have Alzheimer’s.”
C. “Memantine is an herbal alternative to donepezil.”
D. “Memantine is an extended-release version of donepezil.”
141. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take?
A. Contact the client’s family about the incident. B. Report the incident to the AP’s charge nurse.
C. File a complaint with the facility’s ethics committee.
D. Notify the client’s provider about the incident.
142. A nurse is teaching a client who has AIDS and is immunosuppressed about food safety. Which of following information should the nurse include in the teaching?
A. Plan to eat poultry within 3 days of refrigeration.
B. Store perishable foods in the refrigerator at 8.9 degrees C (48 F) C. Defrost frozen food in the refrigerator before preparation.
D. Eat leftover foods within 5 to 7 days of preparation.
143. A nurse is teaching a client about do-not-resuscitate (DNR) orders. Which of the following information should the nurse include in the teaching?
A. The presence of a DNR order indicates that there is no conflict between the client and the family’s wishes.
B. A client can verbally request a DNR order from the provider.
C. A DNR order indicates that the client cannot be prescribed new medications or treatments.
D. Once a DNR order has been implemented, it cannot be changed.
144. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will need to lose 25 percent of my excess body weight prior to surgery.”
B. “I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after surgery.”
C. “I will consume 48 ounces of carbonated beverages daily prior to the surgery.”
D. “I should wait 30 minutes after eating solid foods to drink beverages following surgery.”
145. A director of nursing in a rehabilitation facility is planning to measure the quality of care provided. Which of the following audits should the director plan to use after clients are discharged to gather information about quality of care?
A. Structure audit
B. Concurrent audit C. Outcome audit
D. Prospective audit
146. A charge nurse is assessing client care tasks for the upcoming shift. Which of the following tasks should the charge nurse assign to an RN?
A. Obtaining blood cultures from a central catheter
B. Inserting an endotracheal tube
C. Inserting an epidural catheter
D. Performing a thoracentesis
147. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin?
A. Glargine insulin
B. Insulin aspart
C. NPH insulin
D. Regular insulin
148. A nurse is assessing a client who is on bed rest and notes on calf is 2.5 cm (1 inch) larger in diameter than the other calf. Which of the following actions should the nurse take?
A. Place the client’s legs in a dependent position.
B. Apply a warm, moist soak to the larger calf.
C. Massage the larger calf.
D. Restrict the client’s fluid intake.
149. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
A. Contractions every 5 min that last 30 seconds
B. Montevideo units consistently 300 mm Hg
C. Urine output of 20mL/hr
D. FHR pattern with absent variability
150. A nurse is screening food brought in by a family member for a client who takes phenelzine. The nurse should instruct the family member that which of the following foods can cause an interaction with this medication?
A. Cottage cheese
B. Iceberg lettuce salad
C. Orange gelatin
D. Bologna sandwich
151. A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
A. Digoxin 0.25mg PO daily
B. Cimetidine PO twice daily
C. Epoetin alfa 150 units/kg three times weekly
D. Tetracycline 200mg PO
152. A nurse is collecting a medication history from a client who reports taking aspirin 81 mg daily. Which of the following medications places the client at increased risk for bleeding?
A. Potassium chloride
B. Gabapentin C. Dabigatran
D. Pioglitazone
153. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 1 min with a 45-second duration, and the fetal heart rate is 170 to 180/min. Which of the following actions should the nurse take?
A. Relieve pressure on the umbilical cord. B. Discontinue the oxytocin infusion.
C. Apply an internal fetal monitor.
D. Administer calcium gluconate.
154. A nurse is preparing to obtain a client’s signature on an informed consent form. Which of the following actions should the nurse take first?
A. Inform the client of his right to change his mind.
B. Witness the client signing the informed consent form.
C. Notify the provider if the client has questions about the procedure. D. Ask the client to explain his understanding of the procedure.
155. A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?
A. Speak in a loud tone when addressing the client.
B. Remind the client to eat scheduled meals daily.
C. Place the client in a supine position.
D. Offer the client a blanket to keep warm.
156. A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
A. Heart rate 140/min
B. Capillary refill 3 seconds
C. Cessation of nocturnal enuresis
D. Absence of hypoglycemic episodes
157. A nurse in an emergency department is caring for a client who has received a dose of penicillin and is now anxious, flushing, tachycardic, and having difficulty swallowing. Which of the following actions is the nurse’s priority?
A. Take the client’s vital signs.
B. Administer oxygen.
C. Insert an IV line.
D. Monitor the client’s ECG.
158. A nurse is caring for an adolescent who has ADHD. Which of the following findings should the nurse report to the provider? (EXHIBIT)
A. WBC count
B. Oxygen saturation
C. Aspartate aminotransferase (AST)
D. Weight
159. A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider?
A. Temperature 37.8 degrees (100 F)
B. Heart rate 100/min
C. Albumin level 4.0 g/dL D. WBC count 14,000 mm
160. A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?
A. Drink 1.5 L of fluids each day.
B. Take mineral oil at bedtime. C. Increase exercise activity.
D. Decrease insoluble fiber intake.
161. A nurse is administering a medication to a client. The client reports the medication appears different then what they take at home. Which of the following responses should the nurse make?
A. “I recommend that you take this medication as prescribed.” B. “I will call the pharmacist now to check on this medication.”
C. “Did the doctor discuss with you that there was a change in this medication?”
D. “Do you know why this medication is being prescribed for you?”
162. A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
A. Isolate the client from staff who are pregnant.
B. Administer aspirin to the client.
C. Initiate airborne precautions.
D. Monitor for the development of Koplik spots.
163. PICTURE OF GUYS FACE – ANSWER: (C, UNDER EYE)
164. A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?
A. Have the child take a tub bath each morning.
B. Apply splints to the child’s extremities during the day.
C. Encourage the child to take naps during the day.
D. Keep the child on bedrest as long as pain persists.
165. A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following alterations in the client’s condition should the nurse identify as an indication of the development of a pneumothorax?
A. Pallor
B. Tracheal deviation
C. Slow respirations
D. Bradycardia
166. A nurse is caring for a client who is experiencing cerebral edema. Which of the following actions should the nurse take?
A. Administer corticosteroids
B. Perform multiple nursing activities at one time.
C. Place the client in a prone position.
D. Assess the client for a positive Trousseau sign.
167. A nurse is caring for a school-age child who has sickle-cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take?
A. Place the child on bed rest.
B. Decrease the child’s oral fluid intake. C. Administer meperidine to the child.
D. Apply cold compresses to the child’s joints.
168. A nurse is providing teaching about the administration of gastronomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse include?
A. Administer the feeding over 30 min.
B. Change the feeding bag and tubing every 3 days.
C. Warm the formula in the microwave prior to administration
D. Place the child in a supine position after the feeding.
169. A nurse is caring for a client who has a fracture of the left hip and is in skeletal traction. Which of the following actions should the nurse take?
A. Increase the amount of weight if the client experiences muscle spasms.
B. Remove the traction weights when bathing the client.
C. Ensure there is no space between the traction weights and the bed. D. Provide a trapeze for the client to aid movement in bed.
170. A nurse who is trained as an interpreter has agreed to translate for an older adult client who is assigned to another nurse. Which of the following statements by the nurse who is translating indicates understanding of this role?
A. “I will let the client know that I am available as the interpreter.”
B. “I will receive a small fee for interpreting for this client.”
C. “I will let the client know that an interpreter is unavailable during the night shift.”
D. “I am glad I am available today, but when I’m not, you can use a family member.”
171. A nurse on an inpatient eating disorder unit is assessing an adolescent client who has anorexia nervosa and a BMI of 16.5. Which of the following findings should the nurse expect?
A. Menorrhagia
B. Potassium 4.2 mEq/L
C. Blood pressure 132/86 mm Hg
D. Lanugo
172. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make?
A. “Your bladder should be full prior to me performing this test.”
B. “I will be taking a blood sample to test for changes in your hormone levels.” C. “This test will determine if there is leaking amniotic fluid.”
D. “If this test is positive you will be required to have a non-stress test.”
173. A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which of the following information should the nurse include in the teaching?
A. “You should eat hot foods to reduce your sense of fullness during a meal.”
B. “Lunch should be your largest meal of the day.”
C. “During meals, you should eat foods with a high-calorie content first.”
D. “While eating, you should drink liquids frequently.”
174. A nurse is teaching a client who has GERD and a new prescription for omeprazole delayed-release capsules. Which of the following statements by the client indicates an understanding of the teaching?
A. “I can expect my hands to have tremors while taking this medication.” B. “I should take this medication before my first meal of the day.”
C. “I should decrease my calcium intake while taking this medication.”
D. “I can expect to have black, tarry stools while taking this medication.”
175. A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
A. Head circumference exceeds chest circumference. B. Nontender, protruding abdomen
C. Natural loss of deciduous teeth.
D. Palpable fontanels.
176. A charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter for a female client. Which of the following actions by the nurse requires intervention by the charge nurse?
A. Places the sterile field on a table that remains within her site. B. Opens the sterile kit by unfolding the flap closest to her first.
C. Provides perineal care prior to opening the catheter kit using clean gloves.
D. Uses nondominant hand to expose urethral meatus by spreading the labia.
177. MATH
178. MATH
179. MATH
180. A nurse is caring for a client who has an NG tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first? A. Check the functioning of the suction equipment.
C. Reposition the NG tube.
D. Instill an irrigation solution slowly.
E. Inject 20 mL of air
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