NUR 450 CAT 1 (2019) updated – University of Miami | NUR 450 CAT 1 (2019) updated

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NUR 450 CAT 1 ( 2019) – University of Miami CAT 1 1. A client is comatose upon arrival to the emergency department after falling a roof. The client flexes with painful stimuli, and the nurse det... ermines the client’s Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client’s airway? A. An endotracheal tube B. A nasopharyngeal tube C. An oral airway D. Tracheostomy tube insertion 2. A client is receiving a continuous half strength tube feeding at 50 ml/hr. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? Answer: 200 25 ml x 8hrs = 200 3. The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first? A. Administer oxygen by face mask B. Notify the healthcare provider C. Reset the alarm D. Check the probe position 4. A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30-second interval followed by an apneic period. What intervention should the nurse implement? A. Reassess the respiratory rate, counting for one full minute B. Call a code and initiate cardiopulmonary resuscitation C. Immediately place the client in Trendelenburg position D. Record the respiratory rate and notify the respiratory therapist 5. A retiree with depression complains of feeling “lonely and having no purpose” in life. Based on Erikson’s developmental theory, which questions suggest that the nurse understands the client’s most important emotional need? A. “Where can you go to be with others?” B. “What about your life makes you proud?” C. “How do you spend your days?” D. “What time of the day do you feel lonely?” 6. Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that the client’s symptoms may indicate which condition? A. A cervical laceration B. A normal fourth stage of labor C. Early postpartum hemorrhage D. Inadequate uterine contractions 7. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? A. An older client who fell yesterday and is now complaining of diplopia B. An adult newly diagnosed with type 1 diabetes and high cholesterol C. A client with pancreatic cancer who is experiencing intractable pain D. An elderly client with Alzheimer’s disease complicated by dysphagia 8. The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which action has the highest priority when the nurse implements this prescription? A. Set the flow meter B. Administer oral care C. Pad bony prominences D. Apply a humidifier 9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this nurse take first? A. Review the correct landmarks before the site is injected B. Explain the correct procedure for giving the medication C. Instruct the nurse to select another injection site D. Demonstrate techniques for restraining the infant 10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child’s mother indicates that she understands home care treatment to promote pulmonary function? A. “Cough suppressants can be used four times a day” B. “The oxygen should be kept at 4 to 6 L/min” C. “Chest physiotherapy should be performed at least twice a day” D. “Activities should be planned to avoid physical exertion” 11. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? A. Encourage intake of foods high in vitamin E B. Decrease intake of foods high in fat C. Decrease heavy lifting and bending D. Encourage physical activity 12. The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1 diabetes mellitus. The parents correctly understands signs of hypoglycemia if they include which symptom? A. Sweating B. Increased urination C. Fruity breath odor D. Thirst 13. The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an immobile client. What documentation of this finding is best for the nurse to enter into the client’s record? A. Sacral area red and inflamed B. 2 cm area reactive hyperthermia on sacrum C. Stage 1 pressure ulcer on sacrum D. Client at high risk for pressure ulcer 14. When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her back and upper arms. The child’s aunt tells the nurse that the child’s parents abuse drugs and alcohol. What intervention is most essential for the nurse to implement? A. Notify child’s healthcare provider of the assessment findings B. Determine the reliability of the aunt’s report C. Report the child’s condition to the nursing supervisor D. Report assessment findings to the proper legal authorities 15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed with a seizure disorder in childhood. What is the most likely cause of his present condition? A. Increasing intracranial pressure B. Acute withdrawal from anticonvulsant medication C. A closed head injury D. A central nervous system infection 16. A Chinese-American client who just delivered a baby states that she will not be able to take the prescribed sitz baths to help heal her episiotomy incision because this will cause an unhealthy balance of cold and hot forces. When planning nursing care, what nursing diagnosis has the highest priority? A. Knowledge deficit related to healing process B. Noncompliance related to cultural diversity C. Anxiety related to cultural diversity D. Impaired tissue integrity related to episiotomy 17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning care for this child, which nursing diagnosis has the highest priority? A. High risk infection related to low platelet count B. High risk for fluid volume deficit related to temperature elevation C. Alteration in urinary elimination related to renal damage from disease D. Potential activity intolerance related to anemia 18. During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority? A. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary B. Determine if the client has taken acyclovir (Zovirax) for this outbreak of genital herpes C. Instruct her to avoid sexual intercourse while active, visible lesions are present D. Assess her feelings about therapeutic abortions in the event the infant has been affected 19. The nurse is obtaining a medication history for a client with a new prescription for paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid (Marplan). What intervention is most important for the nurse to implement? A. Instruct the client to use good oral hygiene measures to reduce dry mouth B. Assess the client for an increased sense of well-being once started on the Paxil C. Instruct the client to avoid foods high in tyamine while taking Marplan D. Notify the healthcare provider that the client is currently taking Marplan 20. While performing a skin inspection on a newborn, the nurse finds a small dimple and a dark tuft of hair in the lumbosacral area of the infant’s back. What is the most likely indication of this finding? A. External manifestation of a spinal abnormality B. Expected finding in a newborn C. Uncommon but normal variation in newborns D. Variation often seen in dark-skinned infants 21. What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP)? A. Consider the client’s ability to assist the UAP B. Evaluate the experience of the UAP C. Prioritize each assigned client’s needs D. Determine if family is available to help 22. A female resident of a long-term care facility is being admitted to the medical department. The client has a fractured hip and has methicillin-resistant staphylococcus aureus (MRSA). Which room should the charge nurse assign this client? A. A semi-private room with a client who also has methicillin-resistant staphylococcus aureus (MRSA) B. A private room, and institute blood-borne standard precautions C. A semi-private room with a client who has enterococci resistant to vancomycin (VRE) D. A private isolation room with a vented negative airflow system 23. The nurse is preparing a client for surgery. Which finding indicates that the client is ready to proceed to the operating room (OR) for a scheduled surgical procedure? A. Hemoglobin 10.1 grams B. Client questions which surgery is scheduled C. Clopidogrel (Plavix) received yesterday D. INR results of 3.1 24. The nurse is preparing to administer an intramuscular injection in the ventrogluteal site of a client who weighs 80 kg. What size needle should the nurse select? A. 25-gauge, 1-inch needle B. 27-gauge, 5/8-inch needle C. 21-gauge, 1.5-inch needle D. 20-gauge, 3-inch needle 25. A client at 38-weeks gestation is in active labor, and a vaginal birth after Cesarean section (VBAC) is planned. Vaginal exam indicates that the client is 6 cm dilated, 90% effaced, and at station 0 with intact membranes. As the client’s contraction become stronger, the fetal heart rate decelerates during the contractions but returns to baseline. What action should the nurse take? A. Prepare for an emergency Cesarean delivery B. Set up an amniotomy tray C. Continue to monitor the client’s labor progress D. Apply a fetal scalp electrode 26. An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the risk for urinary incontinence, what action should the nurse implement? A. Maintain a calm and quiet environment B. Review the client’s serum creatinine level C. Obtain a prescription for a hypnotic at bedtime D. Keep the call bell within the client’s reach 27. Which diagnostic tests are most important for the nurse to monitor when providing care for a client with a bowel obstruction? A. Serum albumin and protein B. Serum liver enzymes C. Serum electrolytes D. Gastric pH analysis 28. A 72-year-old male client reports that he has felt depressed since his wife died six months ago. What question is most important for the nurse to ask this client? A. “Have you ever had a loved one die before?” B. “Do you have close friends in whom you can confide?” C. “Are you sleeping and eating well?” D. “Have you ever felt like hurting yourself?” 29. After administering the first dose of newly prescribed to four clients within a thirty minute time frame, the nurse evaluates each client for therapeutic responses or any adverse reactions. Which medication should the nurse evaluate first? A. Clopidrogel (Plavix) B. Nystatin (Mycostatin) C. Enoxaparin (Lovenox) D. HYdromorphone (Dilaudid) 30. What is the most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter? A. Edema at the insertion site B. Paralysis of the face and neck on the side of insertion C. Pain, accompanied by nausea and vomiting D. Shortness of breath 31. The nurse is developing a plan of care for a client who has a prescription for the calcium channel-blocker nifedipine (Procardia) to treat angina pectoris. What is the purpose for administration of this medication? A. Increase heart rate and force of contraction B. Reduce the incidence of clot formation C. Stimulate the vagus nerve to increase heart rate D. Decrease myocardial oxygen demands 32. While transcribing a new prescription, the nurse notes that the prescribed dosage is much lower than the recommended dosage listed in the drug reference guide. Which client data supports this dosage reduction? A. Increasedserum protein B. Increased liver enzymes C. Decreased serum creatinine D. Prolonged prothrombin time 33. The nurse notes that a postoperative adult client’s respiratory rate is 10 breaths/minute. Which factor in the client’s history is the most likely explanation for this finding? A. Postoperative laboratory test results indicate that the client’s hemoglobin is 10.1 gm/dl and hematocrit is 30.4% B. The client has a ten-year history of chronic obstructive pulmonary disease (COPD) C. The PCA pump containing morphine sulfate was discontinued 15 minutes before vital signs were taken D. The client smoked one pack of cigarettes/day for the past 20 years, before quitting smoking 30 days ago 34. The charge nurse working on a postpartum unit is making assignments for a staff consisting of a registered nurse (RN), a practical nurse (PN), and two unlicensed assistive personnel (UAP). Which client should the charge nurse assign to the registered nurse? A. A primigravida who delivered an infant 6 hours ago via vaginal delivery and is now complaining of seeing spots B. A multigravida who is breastfeeding her infant and is preparing for discharge with her infant C. A client who delivered a 10 pound infant 8 hours ago via cesarean section and is now complaining of pain D. A client who had an epidural for a vaginal delivery one hour ago and now needs assistance to the bathroom 35. A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse implement next? A. Provide a high-calorie, high-protein diet B. Initiate parenteral antibiotic therapy C. Administer antiemetic agents D. Encourage partial weight-bearing 36. A child with heart is receiving the diuretic furosemide (Lasix) and has a serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? A. Dietary intake of potassium rich foods B. Skin turgor C. Heart rate and cardiac rhythm D. Urinary output 37. It is determined that a client with breast cancer has metastasis to the liver. What is the most likely explanation for the client’s risk of developing hemorrhagic tendencies? A. The inability of the liver to synthesize clotting factors B. The presence of a lowered red blood cell count C. The loss of clotting factors resulting from chemotherapy D. The loss of serum proteins found in edematous fluid 38. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? A. Pedal pulses B. Breath sounds C. Vital signs D. Gag reflex 39. Which instruction should the nurse provide a client who is taking the conventional antipsychotic medication chlorpromazine (Thorazine) for schizophrenia? A. Immediately report rigidity of the musculoskeletal system or a sudden high fever B. For best effect, take the medication in the morning C. Have the white blood cell count checked routinely D. Notify the healthcare provider if a sore throat or ulcerations in the mouth occur 40. A client is receiving a continuous infusion of normal saline at 125 ml per hour. The nurse prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the prescription. In which sequence should the nurse implement the procedure? (Arrange with first on top and last on bottom) 1. Spike a new bag of normal saline 1000ml using new tubing 2. Open the clamp on the tubing to bleed all air from the line 3. Close the clamp below the pump and at the client’s venous access 4. Place the pump on hold and replace the tubing in the chamber 5. Attach the distal end of the new tubing to the client’s venous 6. Open all tubing clamps to the client and start the pump 41. A client who is wheelchair bound demonstrates a positive Thomas test after admission to the rehabilitation unit. The healthcare provider prescribes positioning the client prone for 30 minutes three times each day to prevent further flexion contractures. Based on this finding, what change in the client’s plan of care should the nurse expect? A. The client will need surgical intervention B. There may be a delay in the rehabilitation process C. A gel should be provided for the wheelchair seat D. Discharge will be sooner than anticipated 42. Prostaglandin E2 (Prostin E2) is prescribed for client who had a missed spontaneous abortion. Which finding should the nurse expect? An increase in A. Fetal heart tones B. Rh antibody production C. Uterine contractions D. Hemoglobin (Hgb) levels 43. A client with a general anxiety disorder is pacing the hallway. The client tells the nurse, “My heart is just racing and sometimes it feels like it’s fluttering. I’m feeling short of breath and dizzy.” What action should the nurse implement first? A. Administer an anti-anxiolytic B. Escort the client to a quiet room C. Initiate a diversionary activity D. Obtain the client’s signs 44. A 22-year-old is involved in a motor vehicle collision and the spinal cord is severed at the second cervical spine (C-2). What is the most likely outcome of this injury? A. Death at the scene of the accident due to respiratory arrest B. Lifetime need to wear a cervical neck and back brace C. Paraplegia without regaining any lower motor functions D. Complete recovery with a chance of having a normal life 45. A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L, but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse take? A. Disregard the advice of the charge nurse and contact the healthcare provider immediately to report the laboratory value B. Ask the nurse arriving at 0700 to report the lab value to the healthcare provider during morning rounds C. Flag the client’s medical record so the healthcare provider will see the results immediately upon arriving on the unit D. Ask the charge nurse to contact the healthcare provider with the laboratory result as soon as possible during the morning 46. The nurse should carefully assess the client with which urinary problem for fluid volume deficit? A. Enuresis B. Polyuria C. Dysuria D. Frequency 47. What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration? A. Follow-up hematological laboratory studies B. Application of warm, moist compresses to the puncture site C. Proper positioning of the client in a prone position D. Use of a compression dressing for firm pressure to the site 48. An outcome for treatment of peripheral vascular disease is, “The client will have decreased venous congestion”. What client behavior would indicate to the nurse that this outcome has been met? A. Wears protective shoes B. Quits smoking C. Avoids prolonged sitting or standing D. Avoids trauma and irritation to skin 49. When assessing a client, the nurse notices a pulsation below the umbilicus. Upon auscultation of the area, a “swishing” sound is detected. Based on these findings, what additional assessment should the nurse perform? A. Measure the blood pressure B. Check for fecal occult blood C. Palpate for bladder distention D. Auscultate the breath sounds 50. An alert and oriented client requiring droplet precautions is placed in a private room at the end of the hallway. Several days later, the nurse finds that the client is restless and anxious. What action should the nurse implement? A. Encourage family members to maintain a regular visitation schedule B. Advise unit personnel to enter the client’s room only when necessary C. Obtain a prescription for a vest restraint from the healthcare provider D. Transfer the client to a semi-private room closer to the nurse’s station 51. An estrogen preparation is prescribed for a client with prostate cancer. The nurse should instruct the client to seek immediate medical attention if what condition should develop? A. Pain in the calves of the legs B. Gynecomastia C. Testicular atrophy D. Impotence 52. A client with carpal tunnel syndrome is in the out-patient surgical unit after an endoscopic carpal tunnel release. What instructions should the nurse provide the client regarding postoperative care? A. Change the dressing after the first 12 hours B. Sip on clear liquids for 24 hours C. Elevate the hand above the heart D. Keep the fingers immobilized until follow-up 53. Which client should the nurse assess first? A client with A. Gastroesophageal reflux who reports increasing episodes of belching and nausea B. Inflammatory bowel syndrome who reports left lower quadrant abdominal pain C. Celiac disease who has developed frequent episodes of watery diarrhea D. An inguinal hernia who has developed abdominal distention and fever in the last 8 hours 54. A client with a chest tube develops sepsis and dyspnea. Based on findings in the client’s medical record, which prescription should the nurse implement first? Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.) A. Initiate .. B. Give the … C. Start IV … D. Place .. 55. The nurse is teaching a client with COPD about health promotion activities. What is the most important advice the nurse should give this client? A. “Avoid vigorous exercise” B. “Avoid heavy meals and eat six small meals daily” C. “If you have not already done so, quit smoking” D. “Limit your intake of high fat foods” 56. A client at 38-weeks gestation complains of abdominal pain. The nurse notes that her abdomen is rigid. What is the probable cause of these findings? A. Abruptio placenta B. Preeclampsia C. Progression to the transition stage of labor D. A low-lying placenta previa 57. The nurse assess the perineum of a client who is complaining of perineal pain 6 hours after a normal delivery, and finds that the client has small perineal (vulvar) hematomas. Based on this assessment finding, which treatment should the nurse implement? A. Prepare the client for surgical excision of the hematomas B. Instruct the client to use a warm water spray over the perineum C. Spray a topical analgesic to the perineum D. Apply cold packs to the perineum 58. Family members of a client who is in hospice care discuss with the nurse their fears that their loved one’s death will be painful. Which intervention should the nurse implement? A. Collaborate with the hospice chaplain to respond to the family’s fears B. Offer the family members assurance that death is not painful C. Notify the healthcare provider of the need to increase the dose of pain medication D. Provide teaching about available pain control options that might be helpful 59. Which nurse’s behavior is a breach of client confidentiality according to the Health Insurance Portable Accountability Act (HIPAA) regulations? A. Mails privileged health information (PHI) through the US postal service B. Calls a client by both the first and last name in a public waiting room C. Tells the ambulance healthcare provider about the client’s history D. Takes home a daily report sheet with the information of the team’s client’s 60. The nurse is assessing a client following hemodialysis. What finding indicates that an expected outcome of dialysis was achieved? A. Decrease in BP B. Hemoglobin WNL C. Increased urinary output D. Weight gain 61. The nurse is performing a routine well-child exam on a 5-year-old. While palpating the lymph nodes, the nurse feels several 0.5 cm nodes in the cervical area that are round, mobile, non-tender, and non-warm to the touch. What do these findings most likely represent? A. An abnormal finding in need of further investigation B. A sign of acute lymphadenitis C. An expected finding for a well child of this age D. An indicator of early stage mumps 62. A client with acute renal failure has many complications. The nurse recognizes what finding as a sign of an immediate life-threatening situation? A. An increased serum potassium concentration B. A decreased hemoglobin C. An increased serum sodium concentration D. An elevated BUN 63. The nurse completes the Leopold maneuvers for a primipara who is admitted in active labor and determines that the fetus in the right sacral anterior (RSA) position. On which quadrants should the nurse place the external fetal heart transducer? (Click the chosen location. To change, click on the new location) Answer: Right-up quadrant 64. The practical nurse (PN) reports the patterns of urinary frequency and volume for several clients. Which finding necessitates further assessment by the RN? A. Voiding 300 ml clear yellow urine q4h B. 400 ml amber urine by straight catheter q6h C. Voiding 50 ml cloudy urine every hour D. Total indwelling catheter output of 1800 ml in 24 hours 65. Before administering diltiazem (Cardizem SR) the nurse notes that the client’s blood pressure is 140/94. What action should the nurse take? A. Administer the scheduled dose of diltiazem and initiate cardiac telemetry monitoring B. Administer the scheduled dose of diltiazem and monitor the client’s blood pressure C. Administer the scheduled dose of diltiazem and contact the healthcare provider D. Hold the scheduled dose of diltiazem and advise the client to remain on bedrest 66. A male client sitting in his room tells the nurse “The CIA put this transistor right here under my left ear. They are transmitting messages. Can’t you hear them? They’re so loud they scare me.” Which response is best for the nurse to provide? A. “Do you think others hear the message?” B. “The messages scare you?” C. “How long have you been hearing the message?” D. “What is the message telling you” 67. The nurse is preparing a discharge plan for an older client who was recently diagnosed with Alzheimer’s disease. Which intervention should the nurse suggest to the spouse if the client becomes uncooperative at home? A. Restrain the client when agitated or combative B. Provide explanations of procedures to the client C. Reinforce reality orientation when the client is forgetful D. Ensure a calm and predictable environment 68. A client in the third trimester of pregnancy reports that she feels some “lumpy places” in her breasts and that her nipples sometime leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? A. Obtain additional data by asking the client if her areolas have become darker B. Recommend that the client wear a supportive brassiere to prevent leaking of fluid C. Rescheduled the client’s prenatal appointment for the following day D. Explain that this normal, but can be assessed further at the next prenatal visit 69. The nurse should instruct the parents of a 2-year-old toddler with Tetralogy of Fallot to immediately contact their healthcare provider if their child exhibits which symptom? A. Assumes knee-chest position B. Becomes pale and lethargic C. Has respiratory rate of 34 breaths/minute D. Clubbing of the fingers 70. A client with end stage renal disease (ESRD) is undergoing peritoneal dialysis. What observation made by the nurse during the peritoneal dialysis treatment warrants immediate intervention? A. A 2,000 ml amount of dialysate was instilled, and 1,500 ml was drained B. A weight loss of 2 pounds since yesterday was recorded after dialysis C. The client complains of abdominal fullness during the dialysis treatment D. The dialysate takes about 20 minutes to drain, and is straw-colored 71. A hospitalized male veteran of a foreign war refuses care from a Middle-Eastern nurse. The client tells the nurse, “I want an American to take care of me!” Which action should the charge nurse take? A. Explain to the client that the nurse is capable of providing competent care B. Reassign the client’s care to another nurse C. Submit a referral to the ethics committee D. Discuss with the nurse the best methods for addressing the client’s biases 72. The community health nurse is attempting to address the issue of child abuse in a large metropolitan area. A primary prevention program for child abuse might include which program? A. Foster care programs for placement of abused children B. High school child development and parenting classes C. Support groups for abused children D. Anger management classes for abusive parents 73. A client’s right to give informed consent is based on which ethical principle? A. Nonmalfeasance B. Justice C. Autonomy D. Beneficence 74. A client who suffered a stroke and is now on a ventilator receives nutritional supplements by the feedings three times a day. The nurse checks the client for a residual volume before administering the next feeding. Which statement best describes the rationale for this nursing intervention? A. Mixing fresh formula with older formula in the client’s stomach often causes nausea B. Retention of feeding in the stomach increases the likelihood of regurgitation and aspiration C. Aspiration of residual feeding is the best indicator that the tube is in the stomach D. The efficiency of gastric digestion should be determined by analyzing the pH of the residual feeding 75. A client has a history of chronic atrial fibrillation. Which instruction should the nurse include in the teaching plan for this client? A. Weigh daily, at the same time, in the same clothes B. Be sure to take the prescribed daily aspirin C. Auscultate apical heart rate every morning for a full minute D. Keep a record of fluid intake and output 76. A client’s telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? A. Prepare for synchronized cardioversion B. Administer atropine intravenous bolus C. Prepare to defibrillate D. Administer lidocaine intravenous bolus 77. It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volume-control device, when initiating IV therapy for a client following which surgical procedure? A. Colostomy B. Total hip replacement C. Femoral-popliteal bypass D. Craniotomy 78. Which strategy is most important for the nurse to use when assisting a client with myasthenia gravis to devise a daily routine? A. Select a physical diversional activity to promote endurance B. Protect extremities from injury resulting from decreased sensation C. Set up daily physical exercise regimen to promote muscle strength D. Perform necessary physically demanding tasks in the morning 79. The nursing diagnosis, “Altered nutrition: less than body requirements,” is included in the plan of care for a client with hyperthyroidism. What primary etiology should the nurse identify when planning care for this client? A. Increased metabolic needs B. Inability to absorb nutrients C. Pain upon swallowing D. Disturbed body image 80. The nurse is triaging victims of a tornado that hit a housing area outside of town. Which client would the nurse issue a black disaster tag to? A. A 29-year-old female who is 40 weeks gestation and having contractions B. A 12-year-old child who has a closed fracture of the right lower leg C. An 88-year-old male who is complaining of chest pain and dyspnea D. A 59-year-old female with head injury whose pupils are fixed and dilated 81. A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a level IV neonatal facility. His respirations are 90/min, and his heart rate is 150beats per minute. Which drug is the transport team most likely to administer to this infant? A. Ampicillin (Omnipen) 25 mg/kg slow IV push B. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV C. Digoxin (Lanoxin) 20 micrograms/kg IV D. Beractant (Survanta) 100 mg/kg per endotracheal tube 82. A 60-year-old female client takes NPH insulin each morning. What would necessitate holding this client’s usual morning NPH insulin dose? A. The healthcare provider prescribed a sliding scale of regular insulin before each meal B. The client is NPO for surgical debridement of a leg ulcer at 11:00 a.m C. Breakfast trays will be 30 minutes late D. The client’s 7:00 a.m blood sugar is 200 mg/dl 83. Two weeks following a fracture, a male client is told by the healthcare provider that a callus has formed at the fracture site. The client expresses concern to the nurse about the significance of this information. How should the nurse respond? A. Offer reassurance that the healing process is progressing B. Advise the client that the callus may need to be removed C. Explain the use of preventive anticoagulants to the client D. Provide an opportunity for the client to express his anger 84. A 25-year-old female client, a dancer, has just had an ileostomy as a result of Crohn’s disease. In evaluating the client’s response to this life change, which behavior would indicate to the nurse that he is coping effectively? The client A. Discusses modified costume designs B. Call the nurse when her ostomy bag is half-full C. Asks the nurse to teach her mother how to do ostomy care D. Notifies her employer that she will return to work within one week of the surgery 85. The nurse is preparing to insert a saline lock for fluid replacement ina client with a fluid volume deficit. Which assessment finding is most relevant to the nurse’s approach to performing the procedure? A. Altered deep tendon reflexes B. Flattened veins C. Thready pulse D. Prolonged capillary refill 86. The nurse reviews the results of a client’s computerized tomograph scan (CT), which indicates that a cerebellar infarction is present. Based on this pathophysiological finding, what nursing diagnosis should the nurse include in the client’s plan of care? A. Impaired walking related to loss of balance and coordination B. Impaired swallowing related to neuromuscular dysfunction C. Disturbed sensory perception, visual, related to homonymous hemianopsia D. Disturbed body image related to ipsilateral facial paralysis 87. Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia? A. Unexplained weight gain B. Itching and rash C. Recent joint trauma D. Disruption in sleep patterns 88. A male client with a history of seizures tells the nurse that he obtained a generic form of his anticonvulsant medication through an online pharmacy, which was much less expensive than the brand name medication he has been taking. Which information about the medication is most important for the nurse to review with the client? A. Bioequivalency B. Onset of action C. Therapeutic index D. Adverse effects 89. The nurse recognizes that the primary purpose of recommending a yearly digital rectal examination (DRE) for all men over the age of 40 is to help detect the early stages of which type of cancer? A. Cancer of the sigmoid colon B. Prostate cancer C. Rectal cancer D. Bladder cancer 90. The nurse is reviewing the medical history of a client who is scheduled for a parathyroidectomy. Which disorder in the client’s history is most likely to be impacted by this surgery? A. Diabetes insipidus B. Gout C. Fibromyalgia D. Osteoporosis 91. A female client reports that she drank ¾ of a liter of a solution to cleanse her intestines for a colonoscopy. How many ml of fluid intake should the nurse document? Answer: 750 92. The nurse observes that a client is receiving oxygen per nasal cannula at 1.5 L/minute as prescribed, but a humidifier is not attached to the oxygen. What action should the nurse implement? A. Assess the client’s mucous membranes B. Call Respiratory Therapy to supply a humidifier C. Remove the nasal cannula from the client’s nares D. Teach the client about the need for humidification 93. A 19-year-old male client is brought to the emergency room by a group of fraternity brothers after a hazing event at the university. The client arrives with a blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3. Which action should the nurse implement first? A. Insert an indwelling catheter to bedside drainage B. Administer Narcan 0.4 mg IVP and repeat in 3 minutes C. Initiate IV access using Lactated Ringer’s solution 1000 ml with thiamine 100 mg D. Place a nasogastric tube and attach to low continous suction 94. The nurse is preparing to administer vancomycin (Vancocin) 500 mg in 200 ml of DW and based on the manufacturer’s recommendations, the nurse plans to administer the dosage over 90 minutes. The secondary infusion pump should be set to administer how many ml/hour? Answer: 133 95. The nurse is caring for four adults clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and a Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm. What intervention should the nurse implement? A. Determine if Client B has two units of packed cells available in the blood bank B. Ask the dietician to add a banana to Client C’s breakfast tray C. Inform Client D that surgery is likely to be delayed until the infection is treated D. Increase Client A’s oxygen to 4 liters per minute via nasal cannula 96. A client is brought to the emergency room following a massive stab wound and is bleeding profusely. The nurse knows that this client is most likely to exhibit what sign? A. Tachycardia B. Fatigue C. Low hemoglobin D. Hypertension 97. When planning nursing care for immobilized clients, the nurse should consider which physiological alterations that frequently occur with immobility? (Select all that apply) A. Irregular heart rate B. Venous pooling C. Bony demineralization D. Urinary stasis E. Decreased respiratory capacity 98. A client who has localized eczematous eruptions on both hands is diagnosed as having contact dermatitis. What instruction should the nurse include in this client’s discharge teaching plan? A. Wear latex gloves whenever outdoors B. Take prescribed antihistamine near bedtime C. Soak hands in warm soapy water three times a day D. Apply an oil-based ointment to the affected areas 99. Before administering a prescribed dose of tetracycline (Achromycin), what serum lab test should the nurse monitor? A. Glucose B. Uric acid C. Calcium D. Creatinine 100. The nurse identifies a priority diagnosis of “Altered comfort related to menstrual cramps” for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client’s teaching plan? A. Abdominal wall strengthening B. Pelvic floor exercises C. Regular aerobic exercise D. Weight-bearing activities 101. A mother brings her 15-month-old son and 6-year-old daughter to the clinic for immunizations. Both children are fretful and obviously have upper respiratory infections. The mother tells the nurse that the younger child ran a fever of 100.2 F following his last immunization. What plan is best for the nurse to implement? A. Rescheduled the older child’s immunization until the upper respiratory infection subsides B. Withhold the younger child’s immunization until allergy studies can be completed C. Explain that a history of a fever after immunizations may indicate the need to alter the scheduled of boosters D. Administer the boosters and instruct the mother to cal the clinic if either child’s temperature exceeds 101 F 102. The nurse is assessing an unresponsive client who ingested an unknown number of meperidine (Demerol) 50 mg tablets. Naloxone (Narcan) 0.4 mg IV is administered, and the client is now responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse? A. Tachycardia B. Rounding headache C. Difficulty in arousing D. Cold, clammy skin 103. The nurse is caring for a client in the Medical Intensive Care Unit. What problem is a client probably experiencing who has an easily obliterated radial pulse and below-normal pressures, including blood pressure (BP), central venous (CVP), pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP)? A. An acute myocardial infarction B. Acute congestive heart failure C. Hypovolemic shock D. Cardiogenic shock 104. The nurse is providing preoperative teaching to a client scheduled for vertical banding gastroplasty. In preparing the client for the immediate postoperative period, which intervention is most important for the nurse to implement? A. Suggest dietary selections of high protein liquids in the immediate postoperative period B. Show the client a nasogastric tube and explain reasons for low intermittent suction C. Prepare for monitoring in the intensive care unit during the first postoperative day D. Refer for psychological counseling to focus on altered body image and behavior 105. A male client with cancer is admitted on the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client’s admission prescriptions include radiation therapy. What action should the nurse implement? A. Advise the client that palliative care measures can be implemented by a hospice in an outpatient setting B. Reassure the client that radiation treatments can often cure or control cancer with minimal side effects C. Consult with the client about his expected goals for his hospitalizations and current treatment plan D. Consult with the healthcare provider about the client’s wish to cancel further radiation treatments 106. The nurse is teaching a client with Addison’s disease about this new diagnosis. What pathophysilogical explanation should the nurse share with the client? A. Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex B. Pituitary dysfunction, such as diabetes insipidus, can occur after a head injury or primary tumor that causes increased intracranial pressure C. End stage renal disease causes hypertension due to decreased renal perfusion that results in an increased secretion of rennin D. Hyperthyroidism is an autoimmune disease that causes anincreased secretion of thyroxine resulting in an increased basal metabolic rate 107. The first day after a cesarean section, when being assisted to the bathroom for the first time, a primipara client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take? A. Check fundal consistency and continue to monitor the lochial flow amount B. Insert an indwelling catheter to empty the bladder and contract the fundus C. Return the client to bed and maintain bedrest until the lochial flow slows D. Massage the fundus and avoid direct pressure on the cesarean incision 108. What is the priority nursing diagnosis for a client with restless legs syndrome? A. Altered tissue perfusion B. Impaired mobility C. Self-care deficit D. Disturbed sleep patterns 109. A client is receiving an IV of 500 ml NS with 20,000 units of heparin at 27 ml/hr. The nurse wants to verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving every hour? Answer: 1080 110. A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. What nursing assessment is most crucial in determining whether therapy should be initiated? A. Is able and willing to comply with complex drug schedules B. Understands the effects and side effects of the various drugs C. Has an adequate social support structure in place D. Meets qualifications for a prescription assistance program 111. Which client is at the greatest risk for suicide and should be managed with close observation? A. A 35-year-old married Hispanic male who recently lost his job B. A 28-year-old Philipino female who lives with her parents C. A middle-aged Jewish female whose mother attempted suicide D. A widowed White male who is a veteran of the Korean War 112. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial thromboplastin time (PTT) of 65 to 95 seconds. The client’s current PTT result is 35 seconds. What action should the nurse implement? A. Decreasing the rate of the heparin infusion B. Leaving the heparin infusion at the current rate C. Increasing the rate of the heparin infusion D. Discontinuing the heparin infusion 113. A client with allergic rhinitis expresses concern about “giving this runny nose” to her young children. What nursing action has the highest priority? A. Assure the client that her are not contagious B. Instruct the client to rest and drink plenty of fluids C. Assess the client’s vital signs and breath sounds D. Reinforce the need for regular hand washing 114. The nurse observes that a client has received 250 ml of 0.9 % normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement? A. Increase the rate of the current IV solution B. Change the IV fluid to 0.45% normal saline at the same rate C. Discontinue the IV and apply pressure at the site D. Decrease the saline to a keep-open rate 115. A hospitalized client’s bronchoscopy specimen culture result indicates the presence of the Mycobacterium tuberculosis organism. Which intervention is most important for the nurse to implement? A. Use only disposable drinking glasses and personal care items B. Don a gown and gloves when handling the client’s soiled linen C. Don a surgical mask before entering the client’s room D. Put the client in a room with a negative airflow system 116. Four clients arrive at the labor and delivery nurse’s station at the same time. Which client should the nurse assess first? A. A 38-week multigravida with biophysical profile score of 4out of 8 B. A 40-week primigravida who reports contractions occurring every 10 minutes C. A 39-week multigravida who is scheduled for a repeat cesarean section today D. A 37-week primigravida with a prescription for serial blood pressures 117. The industrial health nurse who works in a mobile clinic is developing an exposure control plan for blood-borne pathogens. Which topics should be included in this plan? (Select all that apply) A. Masks for respiratory chemicals and toxins B. Puncture-resistant needle containers C. Self-sheathing or needleless medication systems D. Hepatitis B vaccine series E. Negative pressure environments 118. The nurse notes that a client is experiencing supra-ventricular tachycardia (SVT). Which action should the nurse implement? A. Place a crash-cart at the client’s bedside B. Call a code and start CPR immediately C. Assess the client’s heart sounds and vital signs D. Prepare to administer adenosine, an antidysrhythmic 119. A client diagnosed with acute epididymitis secondary to a sexually transmitted disease receives a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which question should the nurse ask the client? A. “How much time to you spend in the sun or using a tanning bed?” B. “Have you ever had an allergic reaction to any other antibiotic?” C. “Do you operate dangerous equipment in your job or for recreation?” D. “Do you drink alcohol and if so what kind and how much a week?” 120. The community health nurse is planning a cardiac rehabilitation program that will be offered in a neighborhood heavily populated by African-Americans. In preparing instruction on health promotion topics for this program, which approach should the nurse use to address these client’s modifiable risk factors? A. Offer a cooking class that incorporates low cholesterol recipes B. Start a support group for African-American males who have had heart attacks C. Help clients complete a medical history form that shows which relatives have hypertension D. Prepare a poster illustrating the high incidence of heart disease among African-Americans 121. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of hypoglycemia. What symptom should be included in the description of early signs of hypoglycemia? A. Polyuria B. Tremors C. Difficulty swallowing D. Bradycardia 122. The nurse identifies the nursing diagnosis of, “Visual sensory/perceptual alterations related to increased intraocular pressure (IOP)” for a client with glaucoma. Which nursing intervention should the nurse include in the plan of care? A. Encourage compliance with drug therapy to prevent loss of vision B. Develop pain management strategies associated with ocular nerve atrophy C. Recognize that damage to the eye can be reversed until late stages of the disease D. Identify coping mechanism related to the eventual loss of peripheral vision 123. Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle ear infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the nurse administer? Answer: 0.23 124. A mother tells the clinic nurse that the healthcare provider wants her to begin introducing solid foods to her 4-month-old infant. The nurse should recommend introducing foods in what order? 1. Rice cereal, iron fortified 2. Strained apple sauce 3. Strain green beans 4. Strain pureed chicken 125. The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The healthcare provider determines the client is in acute renal failure (ARF). Which intervention is most important for the nurse to include in this client’s plan of care? A. Cardiac telemetry B. Hourly neurological assessments C. Renal replacement therapy referral D. Seizure precautions 126. Based on the Braden Risk Assessment Scale, which client is at highest risk? A. A 60-year-old male who is lethargic, with dysphasia, and is experiencing bladder B. A 30-year-old male who is paraplegic and performs self-catheterization q6h C. A 90-year-old female with a history of failing when walking alone at home D. A 50-year-old female who has a draining, infected surgical wound and a fever 127. A client diagnosed with a myxedema coma has assessed vital signs of: T 99.8F, P 92, R 22, B/P 108/70. Based on this information, what intervention should the nurse implement first? A. Assess the client for presence of infection B. Notify the healthcare provider immediately C. Encourage the client to use an incentive spirometer D. Monitor the vital signs q1h for the next 8 hours 128. Following a fracture, a client develops early symptoms of anterior tibial compartment syndrome. In planning care, the nurse identifies the prevention of what problem as the priority goal? A. Infection B. Embolism C. Ischemia D. Ecchymosis 129. The nurse is teaching a client’s caregiver how to cleanse around a wound drain. What is the best way to explain the proper cleansing technique? A. Start at the clean area several inches away from the drain to avoid contaminating the drain B. Start at the most inflames area, to protect the tissue and promote healing C. Start at the area with the most drainage, to avoid infecting other areas D. Start at the drain site, to avoid bringing skin bacteria toward the wound 130. During discharge teaching the mother asks why her premature infant should get monthly Synagis (Palivizumab) injections. The nurse’s response should be based on what information? A. These injections prevent retinopathy of prematurity caused by high levels of oxygen B. Monthly injections promote normal neurological and physical development C. This medication provides surfactant, which helps the lungs mature more quickly D. This drug protects the premature infant from respiratory syncytial virus (RSV) 131. The school nurse is planning an anti-smoking program for high school students. In developing the content for the program, which approach is likely to be most effective with this group of students? A. Have fellow students who smoke describe the problems that smoking causes in their daily lives B. Have a person who has quit smoking talk to the students about smoking cessation C. Show pictures of old men and women who have smoked all their lives and are now dying of lung cancer D. Provide public awareness information from the National Institute of Health 132. The nurse is giving medications to a client who is admitted to the hospital with a diagnosis of diabetes mellitus. After checking the fingerstick glucose at 1630, what dose of insulin should the nurse administer? Answer: 6 133. The nurse’s assessment of a client admitted with a diagnosis of diabetic ketoacidosis (DKA) include: scant urinary output, serum potassium level of 2.5 mEq/L, blood pH of 7.26, temperature 98 F, pulse 128 beats/minute, respirations 36 breaths/minute, and blood pressure 90/52. Which prescription is most important for the nurse to implement? A. Dopamine IV at 5 mcg/kg/minute B. Potassium IV at 20 mEq/250 ml over 1 hour C. Sodium bicarbonate IV at 1 mEq/kg D. Lasix 20 mg IV push 134. In completing the treatment plan for an 11-year-old who was bipolar disorder, the nurse plans outcomes for the nursing diagnosis, “Risk for violence towards peers related to impulsivity.” Which outcome is most important? A. Continues taking all medications as prescribed B. Participates in daily physical exercise to release energy C. States two reasons for taking mood stabilizing medication D. Seeks out staff when having thoughts of harming others 135. Fluids are restricted for a 4-year-old boy with acute poststreptococcal glomerulonephritis (APSGN). Which nursing intervention makes fluid restriction less obvious to this child? A. Pour the full allotment of liquids in a single container and instruct the child to drink a little at time B. Give the child crayons and show him how to record intake and output to help keep him distracted C. Fill regular cups and glasses half-full and don’t say anything to the child because it will not be noticed D. Play a game of tea party and serve the allowed amount of liquids in small medicine cups 136. A 6-month-old male with brochiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates to the nurse that he is experiencing respiratory distress? A. Abdominal breathing B. A high pitched cry C. Respiratory rate of 62 breaths/minute D. Dry, flushed skin 137. The nurse is caring for a client who has a transcutaneous electrical nerve stimulator (TENS) unit that was inserted at the incisional site following a lumbar laminectomy. What information should the nurse teach the client about the action of this pain modality? A. A mild electrical stimulus at the skin surface blocks transmission of pain stimulus B. The spinal cord is stimulated to release endorphins to help ease the pain C. A cartridge inside the unit injects an analgesic into the epidural space to control pain D. Operation of the unit helps to distract the client from experiencing the pain 138. An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would require immediate intervention by the nurse? A. Complains of having chills and is febrile B. Has become agitated, aggressive, and confused C. Is coughing and expectorating purulent secretions D. Has egophony and rhonchi upon auscultation of the breath sounds 139. During a family baseball game, an adult male is hit on the head with a bat, and he is suspected of sustaining an epidural bleed. What is the most important information for the emergency center nurse to obtain from the client’s spouse, who witnessed his injury? A. “Does your husband have advanced directive?” B. “What time of day did the injury occur?” C. “Did your husband report having double vision?” D. “Was your husband knocked out by the blow?” 140. An 86-year-old female client complains to the nurse that she does not like to eat as much as she used to because things taste differently to her now that she is older. The nurse’s response should be based on which fact? A. Older people often use poor taste sensation as an excuse to avoid eating foods they do not like B. Taste sensation decreases in older adults because of diminished gastric secretions C. A loss of appetite often occurs in older adults as a result of a decreased sense of smell D. Poorly prepared meals and eating alone are the usual causes of a decreased appetite in older adults 141. A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instruction? A. Do not attempt to scratch the skin under the cast B. Apply a cold pack to any “hot spots” on the cast C. Keep the left leg in dependent position D. Apply heat to the leg cast 142. The charge nurse is implementing a quality assurance policy and accompanies a nurse while administering medications. The nurse identifies a male client by asking him to state his name prior to administering the medication. Which action should the charge nurse implement? A. Provide a medication irregular occurrence form for the nurse to complete B. Correct the nurse’s action while administering the medication to the client C. Tell the nurse in a private area that the client identification was incomplete D. Take no action since the nurse is administering the medication correctly 143. A mother in the well-baby clinic reports that her 3-month-old infant frequently spits up formula. Based on this complaint, what action should the nurse take? A. Ask the mother whether the vomiting is forceful in nature B. Perform as abdominal examination C. Assure the mother that this is expected in newborns D. Ask the mother to describe the infant’s stools 144. While assigned to care for clients on a surgical unit, the nurse receives a personal phone call about a family emergency that requires the nurse to leave immediately. What action by the nurse is most important? A. Maintain confidentiality regarding the situation leading up to the emergency B. Complete a personnel request form to document the need for leaving early C. Advise the clients that another nurse will assume responsibility for their care D. Notify the charge nurse of the situation and of the need to leave immediately 145. A 50-year-old male client has just been informed that he will require open heart surgery. He tells the nurse, “This will change my whole life. Nothing will ever be the same again.” What action should the nurse implement first? A. Offer reassurance that most men his age can return to their former activities B. Provide client teaching about the postoperative period and rehabilitation program C. Invite a client who has recovered from the same surgery to speak with the client D. Encourage the client to discuss his perceptions of the changes his life will undergo 146. The nurse-manager determines that the frequency of medication errors has remained the same despite the implementation of new policies related to client identification before administering medications. What action should the nurse-manager take next? A. Analyze the frequency with which nursing staff members have implemented the new policies B. Collaborate with the hospital pharmacy department to develop revisions in the existing policy C. Provide additional education programs regarding the need for implementing the new policies D. Determine what additional policies are needed to reduce the frequency of medication errors 147. The nurse is administering oxygen to a client with pulmonary edema when a family member asks the nurse why the client needs oxygen. Which pathophysiological mechanism should the nurse explain to this family member? A. Fluid collects in the chest cavity and keeps the lungs from expanding B. Fluid leaks out of the small blood vessels into the air sacs of the lungs C. The blood supply to the lungs is reduced so the lungs overwork D. The airway fills with frothy, blood-tinged fluid that moves into the lungs 148. During shift report, the nurse learns that a postoperative client has atelectasis. What nursing diagnosis should the nurse expect to include in the client’s plan of care? A. Disturbed body image B. Deficient fluid volume C. High risk for aspiration D. Impaired gas exchange 149. The nurse knows that the blood urea nitrogen (BUN) can be expected to change as one ages. Which statement best explains this expected changes? A. BUN increases because of a decrease in renal functioning and an increase in cardiac output B. BUN increases because of a decrease in renal functioning and a decrease in cardiac output C. BUN decrease because of a decrease in renal functioning and an increase in glomerular filtration rate D. BUN decreases because of an increase in renal functioning and a decrease in glomerular filtration rate 150. A primigravida at 37-weeks gestation presents to the antenatal unit for a nonstress test (NST) because she has not felt her baby move in the last 8 hours. The nurse applies an external fetal monitor and provides the woman with orange juice, but no fetal movement occurs. What should the nurse do next? A. Initiate vibroacoustic stimulation B. Perform a vaginal exam C. Begin a biophysical profile D. Change the mother’s position 151. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about adequate nutrition, which question should the nurse ask the breastfeeding mother? A. “How many times does the baby nurse in 24-hour period?” B. “How many diapers does the infant wet daily?” C. “How satisfied does the infant seem with each feeding?” D. “How long does the baby nurse at each feeding?” 152. The nurse is administering sodium polystyrene sulfonate (Kayexalate) to a client in a acute renal failure. Which normal finding indicates that the medication has been effective? A. Hemoglobin level of 14.5 grams/dl B. Serum potassium level of 4.3 mEq/L C. Serum glucose level of 100 mg/dl D. Serum ammonia level of 30 micrograms/dl 153. In establishing goals for the client’s plan of care, which information is most important for the nurse to consider? A. Evaluation strategies B. Planned interventions C. Nursing diagnoses D. Clustered assessment data 154. The nurse is preparing a discharge teaching plan for the parents of an infant with phenylketonuria (PKU). What dietary instruction should the nurse provide to the parents? A. Modify the type of amino acids consumed B. Remove all protein sources from the diet C. Give apple juice once a day to maintain hydration D. Supplement evening feeding with rice cereal 155. An infant is admitted to the newborn nursery, and is believed to have Down syndrome. Which physical finding might the nurse expect to see? A. Postural hypotonia B. Maxillary hypoplasia C. Fusion of cranial sutures D. Jeneway spots on the palms 156. The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Because the client is receiving Pitocin, the nurse should closely monitor for which complication? A. Fetal tachycardia B. Uterine tetany C. Hemorrhage D. Uterine hypostimulation 157. A female client who has been taking the corticosteroid methylprednisolone (Solu-Medrol) for three weeks reports to the nurse that she has gained ten pounds since starting the medication, and she wants to stop taking it. What is the best response by the nurse? A. Restricting fluid intake can reduce the weight gain caused by corticosteroids B. The weight gain is a desired effect, showing that the appetite has improved C. The medication must be discontinued gradually, tapering the dose each day D. Weight gain is a sign of toxicity, so the medication should be stopped immediately 158. The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first? A. Perform a physical assessment B. Dry the infant under a warming unit C. Determine an APGAR score D. Allow the mother to touch the infant 159. An infant has a medical diagnosis of tracheoesophageal fistula (TFE). What nursing intervention is indicated for this infant prior to surgical repair? A. Feed small frequent meals B. Prepare the child for a barium enema to correct the condition C. Keep suction equipment available at all times D. Give isotonic enemas as prescribed 160. The nurse has identified four nursing problems for a 13-year-old admitted for depression and anxiety. What is the priority problem? A. Ineffective coping related to post-traumatic stress of fire that killed siblings B. Knowledge deficit regarding purpose of medications and side effects C. Ineffective health maintenance related to substance abuse and unsafe sex D. Risk for self-directed violence related to history of self-mutilation [Show More]

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