NUR 450 CAT 2 (2019) updated – University of Miami | NUR 450 CAT 2 (2019) updated

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NUR 450 CAT 2 (2019) – University of Miami CAT 2 1. A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after i... nsertion, which client outcome should the nurse consider to be within normal limits for this client? A. No bubbling in the suction chamber of the Pleuravac B. Serous fluid in the drainage chamber of the Pleurovac C. Fluctuation with respiration in the water-seal chamber of the Pleuravac D. The dry gauze dressing over the insertion site is clean and intact 2. A client has started long-term maintenance therapy with a cardiotonic medication that has a narrow therapeutic index. Teaching the client the signs/symptoms of which adverse effect is most important? A. Displacement B. Toxicity C. Dependence D. Tolerance 3. In caring for a client who is receiving peritoneal dialysis, the nurse should be alert for that what complications? A. Clear dialysate drainage and burning on urination B. An occluded vascular access device and flank pain C. Abdominal pain, tenderness, and rigidity D. Increased serum albumin level, decreased BUN, and increase hematocrit 4. A high fluid intake is prescribed for a client with urolithiasis. The client wishes to know the chief purpose for this intervention. What should the nurse tell the client about this prescription? A. This action is designed to decrease the uric acid in the urine B. The purpose is to increase the hydrostatic pressure behind the stone to assist in its downward passage C. The intent is to increase the specific gravity of the urine, thereby increasing the probability of passing the stone D. The fluids will increase bilirubin excretion, thereby assisting to resolve jaundice associated with stone formation 5. Normal saline 0.9% is prescribed for a client with fluid volume deficit at a rate of 100 ml/hour. Before starting the infusion, the nurse observes that the client’s urine is dark amber in color. What action should the nurse take? A. Start the IV at a keep-open rate until the assessment finding is reported o the healthcare provider B. Insert a saline lock, but do not start any IV fluid until contacting the healthcare provider C. Review the list of PRN medications to see if a diuretic can be administered D. Administer the normal saline at the prescribed rate of 100 ml/hour 6. Which explanation of autonomic cardiac regulation mediated by sympathetic innervations is correct? A. Sympathetic activation boosts K+ efflux and increases the inotropic effect B. Increased Ca+ influx with sympathetic stimulation raises the heart rate C. Sympathetic activation decreases dromotrophy by lowering conduction speed D. Increased Na+ influx with sympathetic stimulation reduces pacemaker firing 7. The nurse learns that a newly admitted adult client has a six month history of recurring somatic pain. During the admission interview, it is most important for the nurse to question the client about what problem? A. Periods of restlessness B. Episodes of tremors C. Feelings of depression D. Nausea and vomiting 8. A pregnant client begins to cry when the UAP tries to assist her in donning a hospital gown, and she refuses to remove an undergarment that is worn in her culture to preserve modesty. What should the charge nurse do first? A. Incorporate individualized cultural care into the nursing plan of care B. Discuss the importance of respecting cultural beliefs with the UAP C. Determine if continued wearing of the garment will compromise care D. Talk with the client to determine alternate means to preserve modesty 9. The nurse is preparing to insert an IV in an adult male client. Which client’s lab value is most important for the nurse to consider prior to inserting the IV? A. Serum sodium of 130 mEq/L B. WBC of 12,000/mm C. Hemoglobin of 12 g/dl D. Platelet count of 60,000/mm 10. A 12-year-old boy who is 54 inches tall is scheduled for x-rays of his hands and wrist to determine growth patterns. The mother asks the nurse why these x-rays are being taken. What explanation is best for the nurse to provide this mother? A. If the growth areas of the bone are closed, then growth hormone therapy can open them B. Hormonal influences on the bone at this age can be determined by x-ray C. Wrist and hand fractures are common among children of small stature D. X-ray therapy is helpful in promoting the effectiveness of growth hormone therapy 11. The nurse is reviewing laboratory results for a client with adrenal insufficiency. Which finding should the nurse report to the healthcare provider? A. Calcium 12 mg/dl B. Sodium 138 mEq/L C. Glucose 110 mg/dl D. Potassium 4.0 mEq/L 12. At 0700 the nurse receives report for a client with chronic intractable pain “who needs morphine every 4 hours during the day shift to control pain.” After reviewing the client’s record, what action should the nurse implement? A. Request a change in the prescribed dose of fentanyl (Duragesic) transdermal patch B. Scheduled the PRN doses of morphine and codeine at the same time every 4 hours C. Correct the shift summary to be consistent with the medication administration record D. Administer a PRN dose of morphine immediately at the IV rate of 1 mg/minute 13. After a client experiences spontaneous rupture of the membranes during labor, the nurse notes a visible prolapse of the umbilical cord. What intervention should the nurse implement immediately? A. Push the presenting part off the cord B. Turn the client to a supine position C. Administer oxygen by face mask at 6L/min D. Prepare the client for a cesarean delivery 14. The nurse is preparing a teaching plan for a client receiving magnesium-based antacids for treatment of gastro-esophageal reflux disease (GERD). Which instruction should the nurse plan to include? A. “Increase fiber and fluids in your diet to prevent constipation” B. “Avoid taking any other drugs 1 to 2 hours before and after taking the antacid” C. “Swallow the antacid with a glass of low-fat milk to help coat the stomach lining” D. “Take the antacids on an as-needed basis whenever you feel bloating or heartburn” 15. The nurse is caring for a young adult male client with facial injuries resulting from a motor vehicle collision. Which client statement indicative of the highest priority for nursing intervention? A. “I am not taking any more medications because they make my mouth dry” B. “I don’t want my family and friends to see me looking like this” C. “My biggest fear is that this injury will cause me to lose my job” D. “I can’t sleep through the night because I awaken with pain when I move” 16. What is the most important primary preventative measure the nurse can emphasize as a means of reducing the risk of developing acute glomerulonephritis in the general population? A. Teach all females to seek medical attention for urinary tract infections B. Encourage all persons to have a yearly physical with a urinalysis C. Use good hand washing techniques to prevent throat and skin infections D. Eat a low salt diet and monitor the blood pressure frequently 17. The mother of a child with cerebral palsy (CP) asks the nurse if her child’s impaired movements will worsen as the child grows. Which response provides the best explanation? A. The outcome depends on the continued development of the brain lesion B. The course of CP is variable but the brain damage is not progressive C. The most common permanent physical disability of childhood is CP D. The classification of CP determines the severity of motor dysfunction 18. There days postoperative, a client’s wound drainage changes in appearance from sanguineous to serous. Based on this finding, what nursing intervention should the nurse implement? A. Monitor the client’s vital signs B. Apply pressure to the wound C. Continue to monitor the wound D. Obtain a wound culture 19. Following the administration of total parenteral nutrition (TNP) via a central line to a client diagnosed with inflammatory bowel disease (IBD), the nurse should expect what outcome? A. A negative nitrogen balance during TPN administration B. A weight loss of 6 pounds within two weeks C. Afebrile with no purulent drainage from catheter site D. Hydration as evidenced by tented skin turgor 20. Based on the principles of asepsis, the nurse should consider which circumstance to be sterile? A. An open sterile Foley catheter kit set up on a table at the nurse’s waist level B. A sterile glove the nurse thinks might have touched her hair C. A one-inch border around the edges of a sterile field set up in the operating room D. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top 21. The nurse is preparing to administer medications to a client who was admitted to the hospital with a diagnosis of deep vein thrombosis (DVT). Which action should the nurse implement? A. Prepare to give a one time dose of Vitamin K 2.5 mg PO B. Give the next oral dose of Coumadin 2 mg C. Administer the next dose of Coumadin 5 mg D. Report the laboratory findings to the healthcare provider 22. The nurse-researcher determines that a strong correlation exists between an increased likelihood of infection with Crystosporidium parvum and clients infected with HIV. Which factor of the epidemiologic triangle plays a primary role in this correlation? A. Environment B. Host C. Agent D. Social 23. A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first? A. Draw blood for hemoglobin and hematocrit B. Inspect the perineum for lacerations C. Obtain a complete obstetrical history D. Perform a fundal massage 24. A nurse is interviewing a client with a history of COPD, who is dyspneic and has a respiratory rate of 36 breaths/minute. Which nursing diagnosis has the highest priority? A. Knowledge deficit B. Impaired verbal communication C. Ineffective individual coping D. Alteration in body image 25. A nurse with 15 years experience working in the emergency room is reassigned to the perinatal unit to work 8 hour shift. Which client is best to assign to this nurse? A. A postpartum client with an infected episiotomy B. A client at 36-weeks gestation who is possibly in labor C. A client in labor who is dilated to 3 cm D. A mother and baby who just delivered 26. Which statement indicates to the nurse that a client understands medication teaching about alendronate (Fosamax)? A. “I will take the medication with a full glass of water” B. “I will lie down for a half hour after taking the medication” C. “I will take this medication with my breakfast” D. “I will avoid milk and yogurt while I am taking the medication” 27. The nurse is preparing to remove the staples from a client’s abdominal incision and observes that the wound edges are fully approximated. What action should the nurse implement? A. Use a staple remover to release the staples from the incision B. Remove every other staple and apply adhesive skin closures C. Cover the wound with a sterile gauze and contact the surgeon D. Assess the length and depth of tunneling around the wound 28. A client at 32-weeks gestation reports to the clinic nurse that she has a new onset of bright red, painless vaginal bleeding. Which intervention should the nurse implement? A. Teach that bleeding is normal due to Braxton-Hicks contractions B. Position the client in a side-lying position C. Obtain a urine specimen, and assess for white blood cells D. Assess for signs of preeclampsia 29. In assessing a client who has just undergone a lung biopsy, the nurse is unable to auscultate breath sounds on the biopsied side and observes that the client is dyspneic and has slight hemoptysis. While contacting the healthcare provider to report these findings, what intervention should the nurse implement? A. Prepare the client for a chest x-ray B. Assess for jugular vein distention C. Position the client with feet elevated D. Obtain a sputum specimen 30. A client who was in a house fire is brought to the emergency department. Which assessment finding should the nurse respond to first? A. The client’s voice is hoarse and nasal hair is singed B. 18% of the body surface has partial thickness (2nd degree) burns C. The bum site pain is rated as a “10” on a scale of 0 to 10 D. Vital signs are BP 180/70 mm Hg, pulse 100 beats/minute, respirations 24 breaths/minute 31. The nurse is conducting assessments at the beginning of the shift. Which client is most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago? A. An adolescent who is receiving azathioprine (Imuran) following a cardiac transplant B. A young female with increased urinary output following administration of IV furosemide (Lasix) C. A middle-aged male receiving prazosin hydrochloride (Minipress) D. An elderly male who received two units of packed red blood cells (RBCs) 32. A male client had a thyroidectomy 24 hours ago, and now complains of cramping in the hand of the arm where his blood pressure is being taken. The nurse notes that his hand is twitching. What intervention should the nurse implement first? A. Notify the healthcare provider immediately B. Review the client’s serum calcium level C. Take the blood pressure in the other arm D. Administer a PRN analgesic 33. A primigravida who is Rh-negative spontaneously delivers a full term infant at home. Two days later, the client and infant arrive at the clinic, and the healthcare prescribes Rho(D) immune globulin (RhoGAM) because the infant is Rh-positive. What action should the nurse implement prior to administering the RhoGAM? A. Assess the infant’s conjunctivas for jaundice B. Ask a second nurse to verify the dosage and client C. Complete a RhoGAM identification card D. Use a filtered needle to administer the RhoGAM 34. A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing diagnosis has the greatest priority for this client? A. Self-care deficit B. Self-care disturbance C. Social isolation D. Impaired social interactions 35. An older female client with cirrhosis of the liver related to alcohol abuse reports to the nurse that her stools look like “black tar”. What action should the nurse take? A. Remind the client that years of alcohol abuse have caused her current health problems B. Tell the client to report to the emergency room immediately for further assessment C. Instruct the client to call the clinic if she notices bright red blood in her stools D. Tell the client that age-related changes in the bowel often result in dark stools 36. The nurse is developing a teaching plan for a client with varicose veins. What instruction should be included in this plan? A. Walk several minutes every hour B. Cross legs at the thighs only C. Use elevators, instead of stairs D. Soak feet in warm water when fatigued 37. A female client who had a kidney transplant 5 hours ago is receiving replacement IV fluids to match urine output. She has had 950 ml urine output over the last hour and has a weak, irregular pulse. The electrocardiogram indicates occasional preventricular contractions (PVC). What is the highest priority nursing action? A. Document urine output B. Monitor for rejection C. Assess serum electrolytes D. Stop intravenous fluids 38. A client with peptic ulcer disease (PUD) is admitted to the emergency room complaining of sudden severe upper abdominal pain. Assessment indicates an extremely tender and rigid abdomen, B/P of 90/60 mm Hg, and pulse of 110 beats/minute. The emergency department nurse should anticipate implementation of which intervention? A. Administering an iced saline lavage B. Infusing the proton pump inhibitor Protonix intravenously C. Preparing the client for emergency abdominal surgery D. Inserting a nasogastric tube to decompress the bowel 39. Pain medication was administered one hour ago to a 3-year-old child who had a short arm cast applied to the left arm three hours ago. The child continues to cry, the fingers are cold and dusky, and the capillary refill is five seconds. Which intervention should the nurse implement? A. Administer additional pain medication B. Assess the child’s fingers hourly C. Prepare to bivalve the cast D. Request a portable STA x-ray 40. The nurse is planning care for a client diagnosed with end-stage cirrhosis of the liver secondary to alcoholism. When assigning care for this client to a practical nurse (PN), what information is accurate for the charge nurse to provide the PN? A. Higher amounts of narcotics are often needed for pain control B. Drug doses are often reduced for clients with liver failure C. Creatinine and BUN blood levels should be monitored daily D. Decreasing ammonia levels may increase susceptibility for infection 41. A male college student returns to the student health clinic one week after receiving a positive mono spot test for mononucleosis and requests a prescription for amoxicillin (Amoxil, Polymox). He is afebrile and complains of fatigue, a sore throat, dysphagia, and extremely swollen glands. What response should the nurse provide? A. Inform the healthcare provider of the client’s request for the prescription B. Emphasize the need to avoid contact sports for at least two weeks C. Clarify that these symptoms will not respond to antibiotic therapy D. Explain that no effective treatment is available for these symptoms 42. A nurse developed an educational program on healthy eating for high schools students. The program consisted of a series of four classes. What finding is indicative of a program outcome? A. 90% of the students rated the instructor as superior B. Students showed interest in the food models used during the second class C. Overweight students lost an average often pounds by the program’s end D. Student surveys showed that they enjoyed the classes 43. While the female psychiatric nurse is on the phone, a male client, diagnosed with an antisocial personality, interrupts the nurse and tells her that he needs to talk to her about something very important. Which action should the nurse implement? A. Hang up the phone and explain the consequences of his behavior B. Ask another nurse to talk with the client until she gets off the phone C. Allow the client to explain what is wrong then finish the phone conversation D. Tell the client she is busy and will talk to him after getting off the phone 44. A client in the first trimester of pregnancy calls the nurse to report she has symptoms of a cold and wants to know if it is safe for her to take the herb Echinacea. Which instruction should the nurse provide this client? A. Check the label regarding use of Echinacea during pregnancy B. Take Echinacea until the cold symptoms are relieved C. Use an herbal tea to relieve the cold symptoms D. Avoid using herbs during the first trimester of pregnancy 45. A female client is admitted to the psychiatric department on an emergency commitment. The client’s husband asks the nurse, “What is going to happen to my wife? Can I take her home now?” Which information should the nurse provide? A. A psychiatric evaluations is required for continued hospitalizations B. Emergency commitment extends to a maximum of 90 days C. Discharge can be completes after arrangements with the business office D. Hospitalization is mandated until a mental health court hearing is held 46. Which technique should the nurse use to assess for manifestations of erythema infectiosum (fifth disease) in a 4-year-old? A. Palpate lymph nodes B. Auscultate breath sounds C. Visualize oropharynx D. Observe physical appearance 47. A male client is scheduled for a cardiac catheterization in the morning. Which interventions should the nurse plan to implement prior to this procedure? A. Explain to the client that he will be asleep during the procedure and will not experience any discomfort B. Offer a clear liquid diet prior to the procedure and hold all medications the morning of the procedure C. Inform the client that he may experience a flushed feeling throughout his body when the dye is injected D. Explain to the client that the procedure will last about 30 minutes and will be done in the x-ray department 48. A male client, who is in end stage renal disease and has been on a waiting list for a transplant for over one year, s told his condition is now terminal. He tells the nurse that he found a Web site with a kidney for sale, and asks the nurse where he can obtain a tissue match analysis. What is the nurse’s ethical responsibility? A. Suggest a support group for renal transplant recipients and their families B. Inform the client that it is a criminal offense to purchase organs in the United States C. Provide the client with a scheduled for the tissue bank mobile unit for his local area D. Report the client’s desires to the healthcare provider and recommend a psychiatric consultation 49. A client is receiving a nitroglycerin infusion at 10 mcg/min. The pharmacy dispenses an IV solution of nitroglycerin 50 mg in 250 ml of DW. The nurse should program the infusion pump to deliver how many ml/hr? Answer: 3 50. A young adult male client is admitted to the emergency room with a bleeding abdominal wound following a motor vehicle collision. He is crying out with pain. His friends report that he often uses cocaine. What nursing diagnosis has the greatest priority? A. Pain related to injuries B. Anxiety related to trauma of motor vehicle accident C. High risk for injury related to cocaine withdrawal D. High risk for injury related to hemorrhage 51. A client receiving oxygen at 2 L/minute per nasal cannula has a change in oxygen saturation from 92% at 0800 to 88% at 1200, but there is no change in respiratory rate during this same time period. What action should the nurse take first? A. Document the saturation level in the medical record B. Increase the oxygen flow from 2 to 3 L/minute C. Remove the nasal cannula and apply a face mask D. Apply the pulse oximeter to a different finger 52. A post-term primipara is admitted to labor and delivery for scheduled induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin (Pitocin)? A. Early labor evidenced by regular contractions every 15 minutes B. Leopold maneuvers indicating a breech presentation C. Sterile vaginal exam revealing 3 cm dilatation D. Biophysical profile results showing oligohydramnios 53. Which member of the interdisciplinary team on a skilled nursing care unit can legally prescribe medications? A. Geriatric nurse practitioner B. Gerontology-certified staff RN C. Certified medication aide D. Licensed physical therapist 54. The parent of a teenage boy who has been admitted to a treatment center because of drug and alcohol abuse tells the nurse, “Sometimes I feel like I hate my own son.” Which response would be best for the nurse to provide? A. “You may hate him now, but treatments has helped many drug and alcohol abusers become wonderful individuals” B. “There is nothing wrong with the way you feel. It is what you do with these feelings that is important” C. “Hating your own son will only make you more unhappy and result in making you feel guilty” D. “I don’t blame you. I would feel the same way if my son had destroyed his life with drugs and alcohol” 55. The nurse observes the unlicensed assistive personnel (UAP) giving a bed bath to a client who is unconscious. The bed is elevated to a high position and the bed’s opposite side rail is raised. Which intervention should the nurse implement? A. Encourage the UAP to use a Hoyer lift to move the client B. Tell the UAP to request assistance giving the bed bath C. Take no action since the UAP is using proper technique to give a bed bath D. Demonstrate the correct way to give a bath to a client who is unconscious 56. A client with an exacerbation of systemic lupus erythematosus (SLE) is admitted for parenteral corticosteroid therapy. What factor is most important for the nurse to consider when assigning a room for this client? The client A. Should not share a room with a client who has an infection B. Should share a room with a client with a similar cultural heritage C. Should not share a room with a client who is immunocompromised D. Needs a stimulating environment with sufficient lighting 57. A 2-year-old child with celiac disease experiences a relapse of symptoms. In developing a teaching plan for the child’s family, which topic should be the nurse’s primary focus? A. Perianal skin care B. Disease complications C. Dietary management D. Chronic disease adaptation 58. The nurse is preparing to teach the parents of a child who had a surgical repair of a myelomeningocele how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure? A. “The purpose of the dressing is to protect the incision from fecal contamination” B. “The dressing will help dry the sutures for ease of removal” C. “We should rapidly remove the tape from the edges of the dressing when changing it” D. “The dressing should be wetted periodically to keep the skin incision moist” 59. The nurse is teaching a male client the self-care skills needed to deal with his newly diagnosed chronic disease, hypertension. Which strategy is most likely to promote the client’s commitment to needed lifestyle changes? A. Emphasize the risks associated with noncompliance to the treatment regimen B. Provide clearly written and easily understandable materials to reinforce the teaching session C. Schedule multiple teaching sessions for the client to demonstrate his psychomotor skills D. Help the client identify ways in which these skills can benefit his quality of life 60. An autopsy is needed based on what pathologic finding that supports the diagnosis of Alzheimer’s disease? A. Cerebral cortex micro-hemorrhages and infarcts destroy motor and sensory functions B. Amyloid B peptide neurofibrils in the neurons of the hippocampus transmissions to the cortex C. Thiamine deficiency alters short-term memory by short-circuiting neuron transmission in the cortex D. An intracranial shift occurs due to the accumulation of venous blood below the dura mater 61. The nurse is reviewing a client’s record. What change in the client’s serum laboratory values indicates an increased risk for impaired drug excretion? A. Increased creatinine B. Increased glucose C. Decreased potassium D. Decreased WBC count 62. Which foods are best for the nurse to offer a bipolar client who is in an acute manic phase and is pacing in the hallway? A. Chicken soup, lettuce salad, doughnut B. Bologna sandwich, ear corn, candy bar C. Steak, baked potato, apple pie D. Hot dog, potato salad, white cake 63. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented? A. Instruct the client in effective techniques to cleanse the glans penis B. Obtain a urine specimen for culture and sensitivity C. Encourage the client to schedule a digital rectal exam D. Advise the client to maintain a voiding diary for one week 64. The mother of an 8-month-old with a medical diagnosis of rotavirus tells the nurse that her child has had watery diarrhea for about 36 hours. Which assessment data supports the history provided by the mother? A. Urine dark amber in color, scanty amount B. Crackles heard bilaterally in all lung field C. Apical pulse rate of 120 beats/minute D. Infant cries vigorously when picked up by the nurse 65. When planning care for a 56-year-old male client who is in respiratory distress, the nurse knows that the standard treatment protocol is to administer oxygen at 4 L/minute. However, the nurse notes that a prescription for only 2 L/minute is provided for this client. What action should the nurse take first? A. Call the healthcare provider to verify the prescription B. Administer oxygen by protocol at 4 L/minute C. Check to see if the client has a history of COPD D. Call the client’s family to see if the client is hypersensitive to oxygen 66. A one-year child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement? A. Ask the parent to rock the child B. Administer diazepam (Valium) C. Give a prescribed analgesic D. Reduce environmental stimulation 67. A school-aged child who is recovering after an appendectomy is working a crossword puzzle. According to Erikson’s theory of psychosocial development, which stage is the child in at this time? A. Initiative vs. guilt B. Autonomy vs. shame and doubt C. Identity vs. role confusion D. Industry vs. inferiority 68. A nurse seeks to alter a provision of a state’s Nurse Practice regarding nurse-client ratios, which the nurse believes to be unsafe. What action is most likely to impact a rulling by the state’s Board of Nursing? A. Send documentation of the problem to the American Nurse’s Association B. File a grievance at the medical center where the nurse is employed C. Send a anonymous letter of concern to the local newspaper D. Meet with the nurse’s representative to the state legislature 69. A client is receiving morphine sulfate 1 mg q10 minutes with a lockout dose of 24 mg per 4 hours via an intravenous patient-controlled analgesia (PCA) pump. Which record, found on the PCA pump history, indicates that the client has used the PCA pump effectively during the previous hour? A. 12 attempts: 6 mg administered B. 1 attempt: 10 mg administered C. 5 attempts: 5 mg administered D. 4 attempts: 24 mg administered 70. A nurse-manager at a long-term care facility is concerned about the health of the nursing staff. Which program should the nurse-manager institute first? A. Place dental floss in the staff restrooms for employee use B. Encourage staff to walk during breaks C. Provide lift devices for immobile clients D. Arrange to start a Weight Watcher program at the facility 71. What explanation is best for the nurse to provide a preoperative client about the purpose of an incentive spirometer? A. Prevents collapse of the air sacs in the lungs B. Helps reinflate the lungs after anesthesia C. Promotes the removal of anesthesia from the lungs D. Improves blood and oxygen supply to the tissues 72. A client is receiving an IV infusion of regular insulin, 50 units in 100 ml of normal saline at 4 units/hour. The nurse should program the infusion pump to deliver how many ml/hour? Answer: 8 73. A client is admitted to the rehabilitation center after having a stroke involving the Broca’s area of the left cerebral cortex. Based on the location of this stroke, which limitation should the nurse anticipate this client will have? A. Problems with coordination and balance B. Loss in ability to read and write C. Difficulty in speech articulation D. Problems with language comprehension 74. An infant is receiving penicillin G procaine (Wycillin) 180,000 units IM. The drug is supplied as 600,000 units/ml. What volume in ml should the nurse administer? Answer: 0.3 75. Six hours after coronary artery bypass (CABG) surgery, the client has a blood pressure of 90/60 mm Hg, pulse rate of 120 beats/minute, and urinary output of 100 ml since surgery. The nurse recognizes that this client is exhibiting symptoms of which condition? A. Acute pulmonary edema B. Congestive heart failure C. Mitral insufficiency D. Cardiogenic shock 76. The nurse is assessing a 3-month-old infant who had a pulmonary yesterday. This child should be medicated for pain on which findings? (Select all that apply) A. Increased respiratory rate B. Restlessness C. Knees drawn to abdomen D. Increased pulse rate E. Increased temperature F. Peripheral pallor of the skin 77. In the differential diagnosis of delirium versus dementia, which assessment finding supports a diagnosis of delirium? A. The confusion started after admission to the hospital B. The client’s attention span has not been adversely affected C. The client’s memory has been markedly impaired D. The confusion has been slowly developing over several months 78. A 65-year-old male client is admitted to the emergency department. He is nonresponsive with dry mucous membranes and rapid breathing. Laboratory results confirm diabetic ketoacidosis, and the nurse plans to administer intravenous insulin. Which IV solution provides the best dilution for regular insulin? A. Normal saline B. Dextrose 5% in ½ normal saline C. Lactated Ringer’s D. Dextrose 5% in water 79. The nurse is feeding a client with Alzheimer’s disease when the client pushes the food away and states, “Don’t do that! You’re making me mad.” What action should the nurse implement? A. Explain the importance of adequate nutrition to the client B. Ask the healthcare provider about initiating enteral feedings C. Encourage the client to eat only small portions of the meal D. Return in 30 minutes to assist the client with the meal 80. A new mother tells the nurse that she does not want her newborn to receive any immunizations. It is the hospital’s policy to routinely administer immunizations to all newborns. What intervention should the nurse implement? A. Administer the immunization after first explaining the hospital policy to the mother B. Screen the baby for immunization sensitivity before administering the immunizations C. Advise the mother to sign out of the hospitals AMA if wishing to refuse the immunizations D. Do not administer the immunizations and document that the mother has refused permission 81. A client’s history indicates a subjective report of diminished sensory function. Which assessment finding by the nurse supports that report? A. Glasgow coma scale (GCS) score of 15 B. Negative 2 point tactile discrimination C. Negative Babinski reflex D. Patellar DRT (deep tendon reflex) +4 82. The mother of a 3-year-old asks the nurse to clarify the healthcare provider’s diagnosis of acute otitis media. What is the most accurate explanation? “It is an inflammation of the A. Inner and outer ear” B. Inner ear” C. Middle ear” D. Middle and outer ear” 83. The nurse is taking a health history a health history of a 46-year-old male client who has smoked cigarettes for 30 years. He has had chronic bronchitis for the past 6 months. What statement best describes the rationale for obtaining information from the family as well from the client? A. Including the family helps to ensure that the client will comply with the treatment regime B. Family members are usually more anxious than the client to get the physical problem resolved C. Poor oxygenation inhibits the client’s memory and renders information unreliable D. Clients tend to grow accustomed to their cough and underestimate their nicotine use 84. The charge nurse is developing the nursing guidelines for a mental health care unit. Which reference is likely to be the most useful in developing these guidelines? A. The Health Insurance Portability and Accountability Act B. The American Nurse’s Association’s Standards of Practice C. The Americans with Disability Act of 1990 D. The Patient’s Bill of Rights of 1990 85. The nurse is preparing a community education program and plans to provide information about the importance of testicular self-examination for males. What description of testicular cancer should the nurse include in the teaching plan? This disease A. Occurs in men of all ages, and available treatments have a low success rate B. Affects young adult males and needs to be treated promptly C. Usually occurs in middle-aged men and is slow growing D. Usually occurs in men over 50 years of age and is associated with prostate cancer 86. During a home visit, the nurse determines that a male client is experiencing symptoms that should be controlled by his prescribed medication. The client states that he forgot when he was supposed to take his medications. What is the priority nursing diagnosis when the nurse develops the plan of care for this client? A. Family coping ineffective, related to medication regimen B. Self-esteem disturbance related to physical symptoms of illness C. Altered health maintenance related to lack of knowledge D. Noncompliance related to medication administration 87. Furosemide (Lasix) is prescribed for a 4-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? A. Daily weight decreased from 47 pounds to 45 pounds B. Serum BUN increased from 9 mg/dl to 14 mg/dl C. Urine specific gravity increased from 1.02 to 1.03 D. Urinary output decreased from 25 ml/hr to 20 ml/hr 88. While changing a client’s postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values? A. Serum electrolytes B. Platelet count C. White blood cell count D. Hemoglobin and hematocrit 89. A client with end-stage renal disease (ESRD) is experiencing systemic pruritis. Which metabolic conditions are the main causes of the development of this symptom? A. Contact dermatitis and hypoparathyroidism B. Metabolic alkalosis and hypophosphatemia C. Uremic dermatitis and azotemia D. Seborrheic dermatitis and hyperalbuminemia 90. Following a thoracentesis, what assessment finding indicates to the nurse that the client is experiencing a complication of this procedure? A. Asymmetry of respiratory movement B. Increased pulse rate and blood pressure C. Clear, watery mucus when coughing D. Inability to demonstrate the cough reflex 91. The nurse anticipates the prescription of a reduced dosage of a nephrotoxic medication for the client with which problem? A. Subjective reports of dysuria with burning pain and cloudy amber urine B. Diminished creatinine clearance found after 24-hour urine collection C. Observable hematuria following a renal biopsy procedure D. Documented presence of a kidney cyst found via ultrasound 92. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which interdisciplinary team member should the nurse consult to assist the client? A. Psychologist B. Hospice nurse C. Pharmacist D. Pain specialist 93. When providing care for a group of clients, which client should the nurse closely monitor for development of acute renal failure (ARF)? The client with A. An anxiety disorder being treated with lorazepam (Ativan) B. Peptic ulcer disease being treated with sucralfate (Carafate) C. A resistant staphylococcus infection being treated with vancomycin HCI (Vancocin) D. Atrial fibrillation being treated with digoxin (Lanoxin) 94. A practical nurse (PN) and a registered nurse (RN) are the only two staff members working the night shift on a small medical unit. The RN notes that the call light of a client assigned to the PN is on and finds the PN asleep in the break room. What action is best for the RN take? A. Report the incident to the nursing supervisor B. Awaken the PN to answer the client’s call light C. Inform the PN that sleeping will not be tolerated D. Advise the nurse to sleep more during the day 95. During a newborn home visit, the nurse observes cracked paint on the walls of an older home. Siblings living in the home include a 1-year-old, a 2-year-old, and a 4-year-old. Besides assessing the newborn, what other action should the nurse take? A. Perform an oral assessment on each child’s teeth and mouth B. Obtain a blood sample to screen for lead poisoning in the older children C. Notify the Occupational Safety and Health Administration about the paint D. Determine the need for a referral to Child Protective Services 96. A client is hemiplegic following a cerebrovascular accident. To prevent this client from experiencing a painful shoulder, what intervention should the nurse include in the plan of care? A. Position the affected arm on pillows while the client is seated in a chair B. Keep the client’s affected arm elevated above the level of the heart C. Avoid range of motion exercises on the affected shoulder until pain in the shoulder has passed D. Exercise the affected shoulder by using it when assisting the client out of bed 97. The nurse is planning care for a male client with a diagnosed personality disorder. To effectively use the milleu for this client, which interventions should the nurse include in this client’s plan of care? (Select all that apply) A. Provide a structured daily routine B. Ask the client what goals are reasonable for him to achieve while hospitalized C. Reinforce adaptive changes in his behavior D. Determine what sports activities the client prefers E. Clarify the consequence of his actions 98. The nurse is providing routine tracheostomy care for a client who has been admitted with pneumonia. Place the following steps of the procedure in t he correct order of implementation. 1. Put on clean gloves 2. Discard soiled dressing 3. Prepare sterile supplies 4. Put on sterile gloves 5. Cleanse inner cannula with H2O2sterile water 6. Replace twill tape and clean dressing 99. A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin (Lanoxin) to her 4-month-old infant, but at 0920 the baby vomited the medicine. What instruction should the nurse provide to this mother? A. Give half dose now and half in one hour B. Give the infant another dose of Lanoxin C. Mix the next dose with food to make it easier to take D. Skip this dose and give the next dose on time 100. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? A. Cervical x-rays B. Synovial fluid analysis C. Lumbar puncture D. Electroencephalogram (EEG) 101. The nurse should question a prescription for docusate sodium (Colace) for a client with which problem? A. Two days following a knee replacement B. History of liver disease C. First day post myocardial infarction D. Abdominal pain of unknown etiology 102. Following vaginal delivery in a birthing suite, the nurse assess a newborn male and finds that his respirations are 58 breaths per minute and his hands and feet are cyanotic. What action should the nurse take? A. Transfer the infant to the nursery to determine his oxygen saturation rate B. Record the findings and continue to observe the infant C. Notify the pediatrician immediately D. Administer oxygen at 5 L/minute 103. The nurse is providing intermittent gavage feedings for a 32-week gestational age newborn. The nurse positions the newborn in a right side-lying position with the head slightly elevated and passes the feeding tube through the mouth. Prior to administering the bolus feeding, it is most important for the nurse to obtain which assessment? A. Gag reflex and vomiting B. Stomach residual volume C. Sucking on gavage tube D. Nasal breathing obstruction 104. A postmenopausal client, who smokes a pack of cigarettes a day, is taking estrogen (Premarin) daily. What instruction should the nurse provide to this client? A. Observe for swelling and calf pain B. Do not stop the drug abruptly C. Drink 8 glass of fluid daily D. Stop the drug if a beta-blocker or thiazide diuretic is prescribed 105. The nurse is performing a routine examination of a 6-month-old girl at a community health clinic. Records indicate that the child weighed 6.5 lbs at birth. The clinic uses kg to describe weight. When assessing this child, approximately what weight, in kg, should the nurse consider to be within normal range for this child? A. 6 to 7.5 kg B. 15 to 18 kg C. 12 to 15 kg D. 9 to 11.5 kg 106. Two days following surgery, a bedfast male client demonstrates leg exercises by tightening his thigh and pressing the back of his knee against the mattress. What instruction should the nurse provide? A. These range of motion exercises will help maintain joint function B. This activity can break a blood clot loose and should not be performed C. Do not perform this exercise while wearing antiembolism stockings D. Continue to perform these exercise frequently while on bedrest 107. The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman’s risk for developing osteoporosis? A. Use of birth control pills until age 45 B. Family history of coronary heart disease C. Obesity D. Cigarette smoking 108. A male client psychosis explains that he was having thoughts that people are trying to read his mind. He does not want to go back to his apartment because he believes that someone is waiting there to kill him. What initial response is best for the nurse to provide this client? A. “These thoughts will go away if you take your medications” B. “Have you been taking your medications every day as prescribed?” C. “It must be frightening to feel that someone wants to hurt you” D. Tell me about the people who were trying to hurt you” 109. The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client’s medication administration record (MAR). Which action should the nurse take to prevent a medication error from occurring? A. Verify the room number on the medication administration record (MAR) B. Compare the medication label with the medication administration record (MAR) C. Check the client’s identification bracelet prior to administering the medication D. Compare the medication administration record (MAR) to the prescription 110. The nurse in the new newborn nursery admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis? A. Skin cracked, parchment-like, with desquamation B. Tachypnea with centralized cyanosis when crying C. Hands and feet cyanotic with lips and tongue pink D. Heart rate of 160 and respiration rate of 48 111. Which finding would the nurse anticipate when assessing a client with osteomalacia? A. Flexion contractures B. Fever C. Joint tenderness D. Pain on weight-bearing 112. The mother of an 11-year-old boy who has juvenile arthritis tells the nurse, “I really don’t want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting”. Which information is most important for the nurse to provide this mother? A. Giving pain medication around the clock helps control the pain B. Moist heat to the affected areas negates the need for pain medication C. Encourage quiet activities such as watching TV to prevent pain D. The child should be encouraged to rest when he experiences pain 113. A client with acute coronary syndrome (ACS) who is sleeping has been in sinus rhythm with occasional premature ventricular contractions for the past 24 hours. What action should the nurse take when the monitor suddenly alarms and shows irregular, wide, and erratic complexes? A. Bring crash cart to the bedside B. Initiate cardiopulmonary resuscitation C. Attach automatic external defibrillator D. Check placement of electrodes 114. The nurse is caring for a client who is in the terminal stage of lung cancer with metastasis to the pancreas. Which issue is most important for the nurse to address when planning care for this client? A. Client’s relationships with significant others B. Adequate relief of pain and discomfort C. Ability to ingest both liquid and solid foods D. Skin care following palliative radiation therapy 115. The healthcare provider prescribes a low dose heparin protocol at 12 units/kg/hr for a client with a possible pulmonary embolism. This clientweighs 144 pounds. The heparin solution contains 25,000 units in 250 ml DW. The nurse should program the pump to deliver how many ml/hr? Answer: 8 116. A male client calls the crisis center and tells the nurse that he wants to die and is planning to commit suicide. What means of suicide should the nurse determine is most lethal if in the client’s possession? A. A loaded gun B. A garden hose C. Two bottles of Prozac D. A bottle of an alcoholic beverage 117. When the nurse is preparing a client for surgery, what has the highest priority in assessing a client’s readiness to receive a preoperative medication? A. A family member is present B. Dentures/prostheses are removed C. Vital signs are documented D. Surgical consent is signed 118. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client? A. Presbycusis B. Cerebral dysfunction C. Presbyopia D. Delirium 119. While obtaining a GI history on a frail elderly female client, the nurse learns that she has dentures, lives alone, no longer drives, and is on fixed income. This client has the highest risk for which problem? A. Decreased ability to perform ADLs B. Injury in the home C. Nutritional deficit D. Constipation 120. A public health nurse teaching a class on diabetes plan to discuss risk factors for developing Type 2 diabetes. Which individuals has the greatest risk for developing Type 2 diabetes? A. A 72-year-old African-American who has a history of hypertension B. A 24-year-old Caucasian male whose father is a Type 2 diabetic C. A 48-year-old Hispanic female who is 5’2” and weighs 230 lbs D. A 36-year-old Italian male who eats a diet high in carbohydrates 121. A female client reports feeling nervous and having a headache. When the nurse assesses her blood pressure (BP) using an automatic blood pressure apparatus, it fails to register because the BP is too high. What action should the nurse take first? A. Retake blood pressure in 30 minutes B. Assess rate and rhythm of the client’s pulse C. Take blood pressure on the other arm D. Report symptoms to the healthcare provider 122. An adult client has been treated for hypovolemic shock for 3 hours. Which findings indicate that the client is positively responding to treatment? A. Cool, pale skin and SaO of 93% B. Increased heart and respiratory rates C. Increasing SVR and decreasing serum sodium D. Decreasing lactate and increasing arterial pH 123. Elastic stockings have been prescribed for a client who is recovering from a myocardial infarction. What is the best time to apply the stockings? A. Mid-afternoon B. Before bedtime C. Noon time D. Early morning 124. The nurse notices a reddened area on the coccyx of a wheelchair-bound client. Which intervention should the nurse implement? A. Carefully rewash the site and apply a DuoDerm patch B. Ask the team leader to document the assessment findings C. Provide a donut-shaped cushion for the client to use D. Encourage the client to shift weight while sitting 125. Which method of anchoring an intravenous infusion catheter demonstrates sound nursing judgment? A. Secure the catheter and place a sterile, transparent dressing over the skin insertion site B. Wrap a strip of tape around the entire circumference of the arm for the length of the catheter inserted C. Elevate the hub of the catheter with a 2x2 gauze sponge, then tape the catheter and tube securely on the top of the extremity D. Use one strip of tape to secure the hub of the catheter and one strip of tape to secure the tubing 126. An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take? A. Notify the unit manager that an emergency court order is needed to allow the surgery B. Continue to prepare the client for the surgery without a signed informed consent C. Ask the woman’s friend to sign the informed consent since the client is unresponsive D. Maintain continuous monitoring of the client until a family member can be located 127. In developing a plan of care for a child with acute lymphocytic leukemia, the nurse identifies the nursing diagnosis of, “Potential for injury related to brushing and bleeding.” What laboratory finding provides supporting data for this diagnosis? A. Thrombocytopenia B. Anemia C. Neutropenia D. Leucopenia 128. A female client complains that she cannot sleep, cries much of the day, and is unable to work. Her healthcare provider diagnosis her as depressed and prescribes monoamine oxidase (MAO) inhibitors. In preparing a teaching plan, what foods should the nurse instruct this client to eliminate from her diet? A. Carbonated beverages, eggs, and alcohol B. Salty foods such as chips, and chocolate C. Fruits with a high acidity such as grapefruit and oranges D. Cheese, beer, and avocados 129. Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control? A. Powerlessness B. Hopelessness C. Social isolation D. Personal identity disturbance 130. A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parents of this child in the diagnosis of cystic fibrosis? A. “Is she ever constipated” B. “Does her urine have a musty odor?” C. “Does she taste salty when you kiss her?” D. “What is her daily intake of milk?” 131. An emergency room nurse is caring for a client with a possible abdominal injury. Grey turner’s sign (ecchymosis in the flank area) is noted. What should the nurse suspect from this finding? A. Retroperitoneal bleeding B. Early disseminated intravascular coagulation C. Abdominal mesenteric artery occlusion D. A femoral vein thrombosis 132. When assessing a client the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, dextroverted, and three fingerbreadths above the umbilicus. What action should the nurse take first? A. Check the hemoglobin to determine uterine hemorrhage B. Massage the uterus to decrease atony C. Assess the bladder for distension D. Provide a stool softener for constipation 133. The nurse is assessing the nutritional status of several infants. Based on date obtained while taking a history, which infant’s family will need additional nutritional guidance? A. A 12-month-old whose mother is giving finger foods B. A 6-month-old whose diet includes rice cereal, fruit and breast milk C. An 8-month-old whose mother is starting to introduce formula in a cup D. A 10-month-old who takes 40 ounces of formula 134. A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent? A. The nervousness is due to the asthma and hypoxia, but should disappear after several bronchodilator treatments B. Rapid dilation of the bronchioles and increased heart rate may cause nervousness and jitteriness C. The bronchodilator treatment contained albuterol, which can cause a fast heart rate and jitteriness D. Bronchodilators may produce excessive coughing, which can contribute to tachypnea and anxiety 135. When the nurse prepares to administer a pain medication to a child, the mother states that she does not want her child to have any more narcotics. What action should the nurse implement first? A. Document the mother’s refusal of the medication in the medical record B. Ask the mother to clarify what she understands about the medication C. Explain that regularly administered analgesics help improve pain control D. Notify healthcare provider of the mother’s refusal of the medication 136. Which technique should the nurse use to assess a client’s eyes for nystagmus? A. Use an ophthalmoscope to examine the retinal structures B. Inspect the bulbar and palpebral portions of the conjunctiva C. Ask the client to hold a brief gaze in specified positions D. Compare size, shape, and reaction to light of both pupils 137. The nurse notes a new prescription for linezolid (Zyvox) IV for a client with nosocomial pneumonia due to methicillin resistant staphylococcus aureus (MRSA), as reported by the findings of the sputum culture and sensitivity. The nurse also notes that the client is allergic to cephalosporins. What action should the nurse implement? A. Consult with the pharmacist regarding the prescription B. Prepare to administer the medication as prescribed C. Notify the healthcare provider of the client’s allergy D. Review the culture report with the healthcare provider 138. The charge nurse in a critical care unit is reviewing client’s conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? A. Pulmonary embolus with an intravenous heparin infusion and new onset hematuria B. Myocardial infarction with sinus bradycardia and multiple ectopic beats C. Adult respiratory distress syndrome with pulse oximetry of 88% saturation D. End-stage renal failure with creatinine of 2.5 mg/dl and urinary output of 10 ml/hr 139. The nurse includes the diagnosis, “Impaired mobility related to weakness and fear of falling” in the plan of care of a postoperative client. Which goal should be added to the care plan o address this diagnosis? The client will A. Be instructed in safety measures B. Not fall during the hospital stay C. Report any weakness to the nurse D. Demonstrate increased mobility 140. Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds and a firm, distended abdomen. Which prescription for the client should the nurse question? A. Metoclopramide (Reglan) intermittent IV piggyback B. Continuous tube feeding at 65 ml/hour via gastrostomy C. Total parenteral nutrition to be infused at 125 ml/hour D. Nasogastric tube connected to low intermittent suction 141. In caring for a client with laryngitis, the nurse observes that the client has a frequent, dry cough while conversing with family members. The client also reports experiencing dysphagia due to pain. What action should the nurse implement? A. Advise the client to restrict intake of oral liquids B. Apply a cold compress to the client’s throat C. Instruct the client to restrict conversations D. Encourage the client to use the incentive spirometer 142. A client is diagnosed with an anxiety disorder. According to behavioral therapy, which cognitive restructuring intervention should the nurse recommend when the client is addressing anxiety-producing situations? A. Take an anti-anxiety medication prophylactically B. Call a friend to discuss the anxiety provoking situation C. Try to avoid situations that cause the anxiety D. Recite a favorite poem when feeling anxious 143. A client is undergoing intracranial surgery. What intervention to decrease periorbital edema should the nurse include in this client’s plan of care? A. Put the client in a tredelenburg position B. Apply moist heat over the eyes C. Patch both eyes for 36 hours D. Apply light, cold compresses over the eyes 144. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client’s arm? A. Administer a topical anesthetic to reduce pain and burning at the site B. Monitor radial pulse distal to the IV site regularly C. Instruct the client to expect temporary burning at the IV site D. Assess the IV site regularly for signs of infiltration 145. When caring for a client who has a pulmonary artery catheter in place, which observation warrants immediate intervention by the nurse? A. The wave form indicates the catheter is in the right ventricle B. The client is experiencing isolated unifocal PVCs C. The pulmonary capillary wedge pressure (PCWP) is 8 D. The pulmonary artery pressure (PAP) is 20/10 146. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Begins to show signs of improvement B. Describes being very depressed C. Has a appetite and neglects personal hygiene D. Is not interested in the activities of family and friends 147. After administering an 8 ounce can of nutritional supplement and two teaspoons of medication, the nurse should document the client’s fluid intake as how many ml? Answer: 250 148. The nurse identifies, “Altered sleep patterns related to hot flashes” as a priority diagnosis for a female client during perimenopause. After implementing the plan of care, which documentation indicates a successful outcome? A. Room temperature reduced to manage symptoms B. Client slept through the night C. Client maintains normal body temperature D. Hypnotic medication administered at bedtime 149. The nurse is teaching a course on care of the elderly to unlicensed assistive personnel (UAP)s. In teaching about confusion in the elderly, which 80-year-old client is at highest risk for the onset of acute delirium? A client who A. Was discharged home following unilateral cataract surgery B. Was just transferred to a rehabilitation unit one week after hip arthroplasty C. Has a spouse just admitted to a critical care unit D. Is one day postoperative an emergency colon resection 150. Low molecular weight heparin therapy is prescribed for a client following a thrombolytic stroke. What precaution should the nurse take during anticoagulation therapy? A. Monitor daily international normalized ratio (INR) values B. Administer the medication in a large muscle group C. Keep protamine sulfate available as a reversal agent D. Teach the client to limit intake of foods rich in vitamin K 151. The nursing staffs of a medical unit are asked to make recommendations regarding the installation of computer workstations on the unit. Which factors should the staff consider as a priority to ensure effective ergonomics? A. Height of the countertop and available lighting in the area B. Distance to client’s rooms and the number of chairs available C. Availability of the chart rack and a dictation area for healthcare providers D. Location of the elevators relative to the entrance of the nursing station 152. Repeated from Version 1 153. A male client with diabetes mellitus reports that he has had trouble following his diet, and the result of his fasting blood glucose test is 90 mg/dl. What action should the nurse implement first? A. Obtain a urine specimen from the client to test for ketonuria B. Assure the client that his diabetes control is within normal limits C. Review the findings of his glycosylated hemoglobin test D. Scheduled the client to attend classes about diet management 154. Initial assessment by the nurse of a client who is admitted to the Emergency Center following a boating accident indicates that the client has chest wall bruising with crepitus, shortness of breath, and a respiratory rate of 40 breaths/minute. Which assessment finding requires the most immediate intervention by the healthcare provider? A. Distension of bilateral neck veins B. Tracheal deviation to the left of the midline C. Paradoxical movement of the chest wall D. Diminished breath sounds over the right lung field 155. After receiving a telephone prescription for a medication to be administered today, in what sequence should the nurse perform these tasks? (Arrange from first to last) 1. Write down the prescription as stated 2. Confirm the accuracy of the prescription 3. Administer the medication as prescribed 4. Ensure the prescription is signed by the prescriber 156. The client in which situation requires the most immediate nursing intervention? A. History of multiple sclerosis, experiencing an acute relapse B. Recent onset of migraines, experiencing vomiting and tinnitus C. Previously diagnosed with epilepsy, experiencing status epilepticus D. Diagnosed with Parkinson’s disease, with new onset dyskinesia 157. The nurse observes nonverbal cues that indicate a preoperative client does not have sufficient knowledge about the impending surgery. What action should the nurse take? A. Notify the surgeon that the client needs further teaching B. Wait the client to verbalize any questions and concerns C. Determine if the client has signed the informed consent form D. Offer to answer any questions that the client may have 158. The nurse is evaluating the effectiveness of a client’s plan of care prior to a client’s discharge. Which action has the highest priority? A. Determine which interventions were effective B. Review the effect of medical treatment on the care plan C. Measure the length of time needed to complete the plan of care D. Establish whether the goal was achieved 159. Which technique should be used to obtain a sterile urine specimen using a straight catheter? A. Use a sterile syringe to obtain the specimen B. Drain the urine from the collection bag into a sterile container C. Discard the first specimen, clamp the catheter, then collect the next specimen D. Drain the urine from the catheter into a sterile container 160. Thirty minutes after a teen-age girl is transferred to the unit following the delivery of a stillborn infant, the nurse finds the teen joking and laughing with her boyfriend and other friends. How should the nurse respond? A. Accept that laughter may be this young woman’s method of coping B. Determine if the joyful behavior is related to ending an unwanted pregnancy C. Ask the friends to leave so that the couple may experience their grief Tell the groupof teenagers that now is the time to talk about their loss [Show More]

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