ATI COMPREHENSIVE FORM B | Contains the Highly Tested 360 Questions and Answers

ATI COMPREHENSIVE FORM B | Contains 360 Questions and Answers 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at ...

ATI COMPREHENSIVE FORM B | Contains 360 Questions and Answers 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how often do you drink alcohol d) Tell me about your school schedule 2) *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene? a) Holding the newborn in an en face position b) Asking the father to change the newborn's diaper c) Requesting the nurse take the newborn nursery so she can rest d) Viewing the newborn’s actions to be uncooperative 3) A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the medication is effective? a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism) b) Decreased blood pressure c) Absence of seizures d) Decrease inflammation 4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching? a) Contact provider if the cord still turns black (it’s going to turn black) b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection) d) The cord stump will fall off in five days (cord falls off in 10-14 days) 5) A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? a) Shivering b) Oliguria c) Bradypnea d) Constricted pupils 6) A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identify as the priority? a) A client that has massive head trauma b) A client has full thickness burns to face and trunk c) A client with indications of hypovolemic shock d) A client with open fracture of the lower extremity 7) A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first? a) A client who has illeal conduit and mucus in the pouch b) Client pleasant arteriovenous additional vibration palpated c) A client whose chronic kidney disease with cloudy diasylate outflow d) A client was transurethral resection of the prostate with a red tinged urine in the bag 8) A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention? a) Place’s cardiac monitoring b) Monitor the clients oxygen saturation level c) Provide standby assist with the client from bed d) Encourage foods high in potassium 9) A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect? a) Feta hypoxia b) Abrupto placentae c) Post maturity d) Head Compression 10) A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis? a) glomerular filtration rate of 14 mL/ minute b) BUN 16 mg/DL c) serum magnesium 1.8 mg mg/dl d) Serum phosphorus 4.0 mg/dL 11) A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take? a) Placed infant under radiant warmer b) Move the probe site every 3 hours c) Heat the skin one minute prior to placing the program d) Placed a sensor on the index finger 12) A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first? a) Client placed in restraints to the aggressive behavior b) A new limited client pleasures history of 4.5 kg weight loss in the past two months c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety d) Applied he’ll be receiving his first ECT treatment today 13) A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? a) Hypnosis focuses on the biofeedback as a relaxation technique b) Hypnosis promotes increased control of her pain perception during contractions c) Hypnosis uses therapeutic touch to reduce anxiety during labor d) Hypnosis provides instruction to minimize pain 14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone you dislike) a) I steal things because it’s the only way I can keep my mind off my bad marriage b) I can’t believe I was accused of something I didn’t do c) I don’t want talk about my feelings right now. We will talk more next time d) I think that people just you’re just lazy and should earn money honestly 15) A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate. Which of the following should the nurse identify as a contraindication to medication? a) Glaucoma b) Hypertension c) Polycythemia d) Migraine headaches 16) ? 17) The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care? a) Draw a troponin level every four hours b) Performance EKG every 12 hours c) Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitation consult 18) A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider? a) WBC 3,000/mm3 b) Hemoglobin 14 g/dl c) Platelet 250,000/mm3 d) aPTT 30 seconds 19) Home health nurse is carefully planned for Alzheimer’s disease. To the following action should the nurse include in the plan of care a) Place a daily calendar in the kitchen b) Replace button clothing with zippered items c) Replace the carpet with hardwood floors d) Create variation in daily routine 20) Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first? a) The client was cystic fibrosis and has a thick productive clock and reports thirst b) Client who has gastroenteritis and is lethargic and confused c) The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over deal d) The client was sick of signing it reports pain 15 minutes after receiving oral analgesic 21) A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate? a) Decrease taking vitamins and supplements to every other day b) Eat 15 g of fiber per day c) Consume 48 ounces of water each day (need at least 64 oz) d) Drink hot water with lemon juice each morning when you wake up 22) ? 23) A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply a) I can’t change my instructions once a minute b) My doctor will need to approve my advance directives c) I need an attorney to witness my signature on the advance directives d) I have the right to refuse treatment e) My health care proxy can make medical decisions for me 24) A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output? a) The chest b) Standing c) Supine d) Left lateral 25) A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP? a) Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry b) Client who has awoken following a bronchoscopy and requests a drink c) Client who had a myocardial infarction 3 days ago reports chest discomfort d) Client who had a cerebrovascular accident two days ago and needs help toileting 26) Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? a) Constipation b) blurred vision c) Fever d) Dry Mouth 27) A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention? a) Providing a high protein snack b) Assisting the child to reposition c) Placing weights as a child’s bed d) Massaging pressure points-causes skin breakdown 28) A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take? a) Determine if the AP is qualified to perform the test. b) Help the AP performed the blood glucose test c) Assign the AP to ask the client is taking his diabetic medication today d) Have AP check the medical record for prior blood glucose test results 29) A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following? a) Alzheimer’s disease b) Schizophrenia c) Substance intoxication d) Depression 30) A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are associated with this diagnosis? Select all that apply a) splenomegaly b) Koplik spots (this is associated with measles) c) Malaise d) Vertigo e) Sore throat 31) Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first? a) Apply skin preparation to wound edges. b) Normal saline c) Don sterile gloves d) Determine pain level 32) A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly? a) Drainage fluid is greenish-yellow b) aspirate pH of 3 c) Abdominal rigidity d) air bubbles noted in the NG tube 33) A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take? a) Piggyback 0.9 sodium chloride with TPN solution b) Check for an allergy to eggs c) Discuss the TPS solution for 12 hours d) Monitor for hypoglycemia 34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?) a) Systemic analgesic effect b) increase in your metabolism c) Decreased capillary permeability d) Vasodilation 35) Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to a) Perform weight bearing exercises b) Avoid crossing the legs beyond the midline c) Avoid sitting in one position for prolonged periods d) Split affected area 36) A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign b) A client who was Clostridium difficile with acute diarrhea c) A client who is acute kidney injury and urine with a low specific gravity d) The client who has oral cancer and reports a sore on his gums 37) Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate? a) Call the provider to clients respiratory rate is less 18/min b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr c) Give the client enalapril 2.5 mg PO twice daily d) Call the provider if the clients pulse rate is less than 80/min 38) A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan? a) I will be able starting this medication with feel better b) I can expect to urinate frequently while on this medication c) I understand I may experience difficulty sleeping on this medication d) I should decrease my sodium intake while on this medication 39) A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?” a) Offer to speak to the client’s husband regarding his abuse behavior. b) Help the client to recognize the signs of escalation of abuse behavior c) Assist the client to identify personal behaviors that trigger abusive behavior d) Assist the client to Reports abusive behavior to the proper authority 40) A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? a) Why do you think your life is not worth it anymore? b) Do you have a plan to end your life? c) I need to know what you mean my misery d) You can trust me and tell me what you’re thinking 41) A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect? a) Decreased level consciousness b) Unable to identify common objects c) Poor problem solving ability d) Preoccupation was somatic disturbances 42) A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take? There are 3 tabs that contain separate categories of data. a) Position the client with the affected extremity lower than the heart b) Administration of acetaminophen c) Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion 43) Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse? a) Expel air bubble at the top of the prefilled syringe b) Massage the injection site to evenly distribute the medication c) Inject the medication the lateral abdominal wall d) Administer an NSAID for injection site discomfort 44) Nurses caring for four clients. Which of the following client data should the nurse report to the provider? a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing b) Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hour following surgery c) Client who is 4 hrs postoperative and has a heart rate of 98 per minute d) The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 45) Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client? a) Promethazine b) Hydromorphone c) Ketorolac d) Amitriptyline 46) A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care? a) Live with the clients fluid intake to 1500 mL per day b) Massage place affected extremity to relieve pain c) Apply cold packs of clients affected extremity d) Elevate the client’s affected extremity when in bed 47) A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take? a) Discontinue oxytocin infusion b) Increased oxytocin infusion c) Decreased oxytocin infusion d) Maintain oxytocin infusion 48) A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client? a) Have your membranes ruptured? b) How far apart are your contractions? c) Do you have any active lesions? d) Are you positive for beta strap? 49) Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should the nurse include? a) Take with meals b) Take at bedtime c) Take with a glass of milk d) Take with a glass of orange juice 50) Four clients present to the emergency department. The nurse should plan to see which of the following clients first? a) A 6 year old client whose left shoulder is dislocated b) A 26 year old client for sickle cell disease and a severe joint pain c) A 76 year old client was confused, febrile and has foul smelling urine - uti d) A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke 51) A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find? a) Leavened bread maybe eaten during Passover. b) Shellfish is commonly consumed in the diet. c) Meat and dairy products are eaten separately. d) Fasting from meat occurs during Hanukkah. 52) ? 53) A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply a) Apply direct pressure to bleeding wounds b) Clean rest last rations and abrasions with hydrogen peroxide c) Cover wounds with a sterile dressing d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccination. 54) The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation? a) Sodium 138 b) Creatinine 1.8 c) Hemoglobin 15 d) Potassium 4.2 55) A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching? a) I understand the methadone tends to slow my breathing b) I understand the methadone may cause me to have difficulty sleeping c) I will avoid alcohol while I’m taking this medication d) I’ll change positions gradually especially from lying down to standing 56) Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation? a) Premature infant with a poor suck reflex and failure to thrive b) An older adults who has difficulty taking in fluids c) Adolescent who anorexia who is cachectic d) A middle aged adults was gastroesophageal reflux disease 57) A nurse is caring for a group of clients. Which of the following client should nurse assess first? a) A client whose benign prostatic hyperplasia and is unable to urinate b) The client was heart failure and report shortness of breath while ambulating c) A client who is open cholecystectomy and has green drainage from the T-tube d) A client whose abdominal pain and is vomiting coffee ground emesis 58) A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure? a) Atorvastatin b) Digoxin c) Nifedipine d) Metformin 59) The nurses assessing client with posttraumatic stress disorder. Which of the following findings to the nurse expect to find? a) Dependence on family and friends b) Loss of interest in usual activities c) Ritualistic behavior d) Passive aggressive behavior 60) A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care? a) Give the client several choices when scheduling activities. b) Confront the client regarding unacceptable behavior c) Maintain Nutritional requirements by offering finger foods d) Stimulate the client by leaving the television on throughout the day 61) A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first? a) A client who has begun to demonstrate catatonic behavior b) The client was compulsive behavior and is frequently drinking from the water fountain c) Client was having auditory hallucinations is becoming agitated d) A client was making sexual comments to clients of the opposite sex 62) A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first? a) Instill erythromycin ophthalmic ointment and the newborn’s eyes. b) Place identification bracelets on the newborn. c) Weigh the newborn. d) Dry the newborn 63) A nurse receives report on a group of clients. Which of the following client should the nurse attend to first? a) A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula b) A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10 c) The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid 64) A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor? a) The client reports the urge to push b) The cervix is dilated 2 cm c) Contractions are 2 to 3 minutes apart d) The client reports nausea and vomiting 65) The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned? a) An AP is to calculate intake and output every two hours for client in acute renal failure. b) An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy c) A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident. 66) A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention? a) pruiritus under the cast b) Localized stabbing pain upon movement c) paresthesia of the distal extremity d) Edema present when leg is in the dependent position 67) The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action? Click on the links of this below for additional client information a) Offer the child a cup of chicken broth. b) Encourage the child’s intake of gelatin. c) Administer oral rehydration solutions. d) Institute a banana, Rice, applesauce, and toast diet. 68) The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? a) Serum chloride b) Uric acid level c) Serum albumin d) Magnesium level 69) A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion? a) Ventricular asystole b) Third-degree AV block c) Atrial fibrillation d) Ventricular fibrillation 70) Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions? a) Scarlet fever b) Herpes simplex c) Varicella d) Streptococcal pharyngitis 71) A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately? a) The clinic experiences coughing and wheezing after eating. b) The client reports abdominal pain at a five on a scale of 0 to 10. c) The client experience is a drop in oxygen saturation to 91% while eating. d) The client reports a burning sensation in epigastric area. 72) A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP? a) Applying condom catheter for client for spinal cord injury b) Administrative oral fluids to client was dysphasia c) Documenting the report of pain from client who is postoperative d) Reviewing active range of motion exercises with a client who is had a stroke 73) A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC? a) Candida albicans b) Herpes simplex virus 2 c) staphylococcus aureus d) Lyme disease 74) The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse? a) A pain score 7 on a scale of 0 to 10 b) Shortness of breath c) New onset of a new enuresis d) Priapism 75) Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse? a) Glascow scale score a 15 b) Blood drainage on initial dressing measuring 3 cm c) Report of dry mouth d) Urinary output greater than fluid intake 76) A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client a) Flexes elbows at 30 degrees when using the handgrips b) Maintains 3 to 4 finger width between the crutch pad and axilla c) Places the crutches 6 inches in front and side of each foot when standing. d) Pushes up from a chair with crutches on the unaffected side. 77) A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? a) Use a designated stethoscope when caring for the toddler. b) Wear an N95 respiratory mask while caring for the toddler. c) Remove the disposable gown after leaving the toddler’s room d) Place the toddler in a room with negative air pressure. 78) A nurse is admitting to a client to emergency department and initiates continuous cardiac monitoring. Which of the following ECG with strips indicates sinus tachycardia? b) 79) A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the plan of care? a) Massage lower extremities daily to prevent DVT b) Limit intake of Food high in calcium to prevent renal calculi. c) Encourage client to lie supine prevent constipation. d) Remove anti embolism stockings for 3 hours each day to decreased skin breakdown. 80) A nurse discovers that the wrong dosage of medication was given to client. When determining what action to take your should recognize that which of the following ethical principles should be applied? a) Utility b) Paternalism c) Veracity d) Fidelity 81) ? 82) A nurse is review in the prescription for doxazosin with a client. Which of the following should be included in the teaching? a) Decrease caloric intake to reduce weight gain. b) Increased dietary fiber to prevent constipation. c) Rise slowly when sitting up from bed. d) Take this medication each morning. 83) Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching? a) Exercising an hour before bedtime b) Take a short nap today c) Keep bedroom cool at night d) Consume a high carbohydrate snack at bedtime. 84) A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions is appropriate? a) Wear a face shield prior into entering the room. b) Place the client private room. c) Place the client in a negative pressure room. d) Use alcohol based hand rub following client care. 85) A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following intervention should the nurse including the plan of care? a) Perform active range of motion exercises. b) Perform neurological checks every 4 hours. c) Suction the airway frequently. d) Maintain the head at a midline position. 86) The nurse is assessing a client is receiving radiation therapy. Which of the following findings should the nurse expect? a) White blood cell count at 12,500 mm3 b) Excessive salivation c) +3 pitting edema d) Platelets 95,000 mm3 87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medications is contraindicated? a) Methylergonovine. b) Misoprostol c) Dinoprostone d) Oxytocin 88) A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect to find? a) Shortness of breath b) Rebound tenderness c) Atypical chest pain d) Vomiting blood 89) A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action? a) Ensure eye shield is covering the eyes. b) Apply lotion to expose skin. c) Offer glucose water between feedings. d) Discontinue breast-feeding during treatment. 90) This is assessing clients as had a long arm cast. Which of the following findings of the dress moderate and when assessing for acute compartment syndrome? a) Shortness of breath b) Petechiae c) Change in mental status d) Edema 91) I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse? a) Placed the client in a prone proposition. b) Implement Positive pressure ventilation. c) Perform nasopharyngeal suctioning. d) administer flumazenil 92) A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actions should the nurse take first? a) Report the AP’s behavior to the supervisor. b) Completed instant report regarding the Aps conversation. c) Provide the AP with written documentation regarding client confidentiality d) Tell the AP to discontinue their conversation 93) A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following? a) testicular Cancer b) Obesity c) Stroke d) Melanoma 94) A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following prescription is given by the provider should the nurse clarify? a) Over the fact that extremities and two pillows. b) Apply heat to affect extremity for 45 minutes on the 45 is off. c) wrap the affected extremity with a compression dressing. d) Assess the affected extremity for sensation movement impulse every four hours 95) A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the following food selections indicates that client understands teaching? a) A sandwich and milkshake b) Rice with black beans c) Cottage cheese and tuna lettuce d) Three egg omelette with low-sodium ham 96) A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a) Remove dirty linens from the room after double bagging. b) Wear a dosimeter film badge while in the client’s room c) Limit each of the clients is yours to one hour per day. d) Ensure family members remain at least 3 feet from the client. 97) A nurses for Caring for four clients. Which of the following client should the nurse care for first? a) A client to receive a chemotherapy treatment or first national b) A client who has an appendectomy to these don’t has diminished all sounds c) A client is hypothyroidism and his stuporous d) A client who is a burn requiring a sterile dressing change 98) The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care? a) Initiate droplet precautions for the client b) Assisted client to supine position c) Performing Glasgow coma scale every 24 hrs d) Recommend prophylactic acyclovir there for the clients family. 99) Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that the teaching has been effective when the client states. a) I want sure that my medications are enteric coated b) My stoma will drain liquid fluid continuously c) I will change my pump system every two weeks d) My stoma size will stay the same even after healed 100) A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to use in combination oral contraceptives? a) thyroid disease b) Allergy to penicillin c) impaired liver function d) abnormal blood glucose 101) The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching? a) This medication can be used to help you when have an acute asthma attack b) This medication should be taken before exercise and physical activity c) This medication can be taken for 10 days and then gradually discontinued d) This medication helps decrease swelling and mucus production 102) I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first? a) A client who is receiving warfarin and has and INR of 3.3 b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL c) A client who had a NG tube inserted 6 hr ago and has abdominal distention d) A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat 103) A nurse is assessing a client who has pericarditis. Which of the following findings is priority a) Paradoxical pulse pg. 389 under complications b) dependent edema c) Pericardial friction rub d) Substernal chest pain 104) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching? a) Hydrogen peroxide b) Chlorhexidine c) Isopropyl alcohol d) Chlorine bleach 105) *A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take? a) instruct the client to lift her chin when swallowing b) discourage the client from coughing during feedings c) Sit at or below the clients eye level during feedings. d) Talk with the client during her feeding. 106) A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a) Assault b) Battery c) Malpractice d) Negligence 107) A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following? a) Re-Evaluate priorities halfway through the shift b) Delegate changing sterile dressing for licensed practical nurse c) Groups activities for the Same client d) Works on several tasks simultaneously 108) A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority finding? a) Feeling flushed and warm b) Abdominal fullness c) Swollen lips d) Metallic taste in mouth 109) A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate? a) Just the flow rate of the clients oxygen tank b) Collecting urine sample c) Measuring the clients pain level d) Monitoring blood glucose levels 110) A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure? a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92 111) A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report? a) A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump has malfunctioned c) A client who requires insertion of NG tube due to a bowel obstruction d) A client who is absent bell sounds following a gastrectomy 112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor? a) Fasting blood glucose b) Carbohydrate intake c) Hematocrit d) Weight 113) The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse? a) I can wear support bra b) I will play cold compression my breasts c) I will manually express breastmilk d) I can take a mild analgesic 114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity? a) Blood glucose of 150 mg/dL b) Urine output of 20 mL per hour c) Systolic blood pressure at 140 mm Hg d) BUN 20 mg/dL 115) The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following findings are indicative of cold stress? a) Respiratory rate of 60 per minute b) Jitteriness of the hands c) Diaphoretic d) Bounding peripheral pulses in all extremities 116. A nurse is planning care for four clients. Which of the following clients is the highest priority? a. A client who is dry, black eschar on the heel b. A client who is wearing an arm cast and reports numb fingers c. The client was reddened skin area with blanching around the coccyx d. The client who has frequent incontinence 117. A nurse is caring for a male adolescent client who has heart failure. Based on the client’s chart finds. Which of the following actions should the nurse plan to take? a. Withholds spiranolactone b. Administer ferrous sulfate c. Administer furosemide d. Withhold digoxin (0.8-2.0) 118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding? a. Confusion (hypoglycemia) b. Thirst c. Diaphoresis (hypoglycemia) d. Shakiness (hypoglycemia) 119. A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication? a. Eggs b. Milk c. Shrimp d. Peanuts 120. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this finding which of the following in the client’s chart? a. Echolalia b. Associative looseness c. Neologisms d. Concrete thinking 121. A nurse caring for a client who is receiving total parental nutrition. Which of the following assessment findings required immediate intervention by the nurse? a. prealbumin level of 20 mg/dL b. Weight increase of two kg/day c. Temperature of 37.6°C d. Blood glucose level of 120 mg/dL 122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been treated for myocardial function. The following is an expected finding for the client? a. Troponin 1 (TNI) 8 ng/ml b. Brain natriuretic peptide (BNP) 10 ng/L c. Alanine aminotransferase (ALT 45 unit/L d. High density lipoprotein (HDL) 75 mg/dl 123. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment? a. paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg c. HCO2 level of 25 mEq/L d. pH level of 7.37 124. A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching? a. "Carbohydrates should be at least 45% of your caloric intake." b. "Protein should be at least 55% of your calorie intake." c. "Carbohydrates should be at least 30% of your caloric intake." d. "Protein should be at least 60% of your caloric intake." 125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? a. 2100 b. 0900 c. 1300 d. 1800 126. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? a. diaphoresis b. polyuria c. abdominal pain d. thirst 127. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? a. Frequency and dysuria b. Profuse milky white discharge c. Hematuria d. Low grade fever 128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding? a. beef broth b. oatmeal c. apple juice d. toast 129. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first? a. A client who reports tingling in the fingers following a thyroidectorny b. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr c. A client who is in a long leg cast and reports cool feet bilaterally d. A client who has a productive cough and an oral temperature of 36° C (96.80 F) 130. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods? a. spinach b. peanut butter c. ground beef d. carrots 131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? a. You only need to receive Rh immune globulin if you have a positive blood type." b. You should receive Rh immune globulin within 72 hours of delivery." c. "Both you and your baby should receive Rh immune globulin at your -week appointment." d. "immune globulin is not necessary since this is your second pregnancy." 132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate? a. You had no way of knowing this would happen." b. Most parents blame themselves when losing a child." c. Tell me why you feel this is your fault." d. You appear to be feeling overwhelmed" 133. A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching? a. “If I eat 500 fewer calories per day, I should lose 1 pound per week.” b. “ If I eat 500 fewer calories per day, I should lose 1 pound per week." c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week." d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week." e. "If I eat 300 fewer calories per day, I should lose 1 pound per week.” 134. A nurses is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching? a. Provide an orthodontic pacifier for comfort. b. Offer fluids by using a straw. c. Cleanse suture line with a cotton tip swab. d. Remove elbow splints periodically to perform range of motion. 135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Perform chest compressions during cardiac resuscitation. b. Perform a dressing change for a new amputee. c. Assess effectiveness of antiemetic medication. d. Provide discharge instructions 136. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox? a. Bloody diarrhea b. Ptosis of the eyelids c. Descending paralysis d. Rash in the mouth 137. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse? a. Aspirate the irrigation solution from the bladder. b. Insert the tip of the irrigation syringe into the catheter opening. c. Apply sterile gloves. 1296 in med surgical book d. open the flow clamp to the irrigating fluid infusion tubing. 138. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication? a. Lipsmacking b. Agranulocytosis c. Clang association d. Alopecia 139. A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care? a. Place the client in seclusion when she is confused. b. Request a prescription for PRN restraints when the client is wandering. c. Dim the lighting in the clients room. d. Leave one side rail up on the clients bed. 140. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management? a. Postorandial blood glucose b. Glycosylated hemoglobin - Ha1c c. Glucose tolerance test d. Fasting blood glucose 141. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? a. Initiate a dietary consult for a toddler. b. Administer a glycerin suppository to a preschool-age child. c. Evaluate gastric residual following intermittent feeding of an adolescent. d. Transport a school-age child to x-ray. 142. A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? a. sodium 130 mEq/L b. Blood pressure 156/90 mm Hg c. Potassium 5.2 mEq/L d. Pulse 54/min 143. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse? a. Apologize to the others for your behavior." b. I am disappointed that you continue to act out when you are angry." c. Come outside with me for a walk." d. If you dont calm down, you will have to go into seclusion." 144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. Which of the following precautions should the nurse take while caring for this client a. Wear an N95 respirator while caring for the client. b. Use a dedicated stethoscope for the client. c. Insert an indwelling urinary catheter to monitor urinary output. d. Monitor the client’s vital signs every 8 hr. 145. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia? a. serum sodium 138 mEq/L b. Urine specific gravity 1.001 c. serum calcium 10 mg/dL d. Urine pH 6 146. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard? a. A client’s wrist restraints tied to the bed rails b. A clients bedside table placed across the foot of the bed c. A meal tray left at the bedside from breakfast d. A call light extension cord pinned to the bedspread 147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? a. I’d like to know more about what’s bothering you." b. "Why are you feeling this way" c. "You did the right thing by bringing him here." d. "I’m sure your father doesn’t blame you." 148. A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge? a. start each meal with a protein source. b. Consume at least 25 g of fiber daily. c. Check your blood glucose level before each meal. d. Limit your meals to three times per day. 149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? a. Tidaling with spontaneous respirations b. Drainage collection chamber is 1/3 full c. 1 cm of water present in the water seal chamber d. Suction chamber pressure of -20 cm H20 150. A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, “I wonder when the doctor will tell us what’s going on" Which of the following actions should the nurse take first a. Request that the provider provide more information to the family. b. Refer the family to a support group for grief counseling. c. Offer to answer questions that family members have. d. Ask the family what the provider has discussed with them. 151. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is a. scaly and red b. asymmetric, with variegated coloring c. firm and rubbery d. brown with a wart-like texture 152. A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process? a. Decreased sense of taste b. Decreased blood pressure c. Increased gastric secretions d. Increased accommodation to near vision 153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care? a. Administer disulfiram. b. Provide frequent orientation to time and place. c. Engage the client in group therapy. d. Perform gastric lavage. 154. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) a. Top left site 155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult? a. Nursing manager colleagues b. Evidence-based practice data c. Hospital administrators d. Protocols in other hospitals 156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) a. Facial flushing b. Syncope c. Diaphoresis d. Vertigo e. Bradycardia 157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. feelings of dread b. rapid speech c. purposeless activity d. heightened perceptual field 158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task? a. "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place the glucometer into the docking station." b. "Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90." c. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of breath." d. "Turn the client in room 126 to prevent pressure areas on his hip bones." 159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? a. Nicotine withdrawal b. Heroin intoxication c. Alcohol withdrawal d. Amphetamine intoxication 160. A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia? a. Abnormal movements of the mouth b. Inability to stand without assistance c. Paralysis of the right arm d. Loss of appetite 161. *A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include? a. The client should notify the nurse when administering a dose of the medication. b. The client can administer a dose of medication every 6 to 8 min. c. The client should be cautious to avoid overmedication (OD). d. Family members can administer a dose the client. 162. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which of the following actions should the nurse take next a. Document the procedure. b. Measure the drainage. c. Record the color of the drainage. d. Label the specimen. 163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Notify security to monitor the facility exits. b. Place the client in seclusion. c. Inform the client of the risks involved if she leaves. d. Call the provider for a discharge prescription. 164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration? a. Recent blood transfusion b. Allergy to penicillin c. Minor acute illness d. Low-grade fever 165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? a. Ventrogluteal b. Dorsogluteal c. Vastus lateralis d. Rectus femoris 166. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? a. Wearing underwear with a cotton crotch b. Wiping from front to back c. Using perfumed toilet paper d. Urinating immediately after intercourse 167. A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching? a. "I will take my morning pills with food or milk." b. "I will weigh myself every day." c. "I will notify the nurse if I have muscle cramps." d. "I will limit my intake of fish." 168. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? a. hepatits C b. peptic ulcer disease c. bronchitis d. chrohn’s disease 169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care? a. Encourage a diet high in calcium. b. Provide a diet high in potassium. c. Ensure increased fluid intake. d. Restrict protein intake to the RDA. 170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first? a. Take vital signs. b. Assess lochia. c. Massage the fundus. d. Give oxytocin IV bolus. 171. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform a. Give 100 mL of water with every feeding. b. Obtain gastric residuals every 24 hr. c. Position the head of bed at 30 degrees during feeding. d. Mix the clients medications with the tube feedings. 172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective? a. Skin turgor displays tenting b. Flat anterior fontanel c. Cool, mottled skin d. hyperpnea 173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching? a. Remove dye markings after each radiation treatment. b. Apply a warm compress to the irradiated site. c. Wear clothing over the area of radiation treatment. d. Use a washcloth to bathe the treatment area. 174. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective." b. "Take your iron medication with fluids other than coffee or tea." c. "It is important to take your iron medication on a full stomach." d. "If you miss a dose one day, take two doses the next day." 175. 175 A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess a. A client who had a hip arthroplasty reports pain and erythema in his calf b. A client who has anorexia and peripheral edema c. A client who has Addison's disease with a blood glucose level of 75 mg/dL d. A client who had a barium enema 2 days ago and reports constipation 176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer? a. Albuterol sulfate b. Hydromorphone c. Diphenhydramine d. Amitriptyline 177. A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take? a. Ask the assistive personnel to assist the client in signing consent for treatment b. Ask the child to interpret for the client. c. Ascertain what language the client speaks and get an interpreter. d. Try to find an adult relative to help the client communicate. 178. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take? a. Position the client supine. b. Prepare an IV bolus of dextrose 5% in water c. Administer calcium gluconate IV. d. Administer methylergonovine IM. 179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the clients last period was October. What is the expected delivery date? (Provide the date using four numerals, the first two for the month and the second two for the day. For example, January 2 0102) a. 0711 (July 7, 2011) Formula: +1 year, -3 months, +7 days 180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is scheduled for chemotherapy and has a hemoglobin of 9 b. A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP) and has small blood clots in the urinary catheter c. A client who is receiving a blood transfusion and reports low-back pain d. A client who has a new colostomy with a reddish-pink stoma 2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? 3 an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60 5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first? 6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first? 7 A nurse is caring for a client who is receiving a localized epidural analgesia infusion. Which of the following nursing actions is appropriate? 8 A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? 9 A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? 10 A nurse in the emergency department caring for a client who has abdominal pain. Which of the following actions by nurse demarcates veracity? 11 A nurse is about to administer an injection to a client who states, “I don’t want that injection. The last time I got that I was sore for a week.” The nurse goes ahead and administers the injection against the client’s wishes. The nurse committed which of the following? 12 A home health nurse is assessing a client who is receiving from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure? 13//// 14 A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients? 15 A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? 16 A nurse is caring for a mother who prescribed methadone during pregnancy. The nurse should assess the newborn for which of the following manifestations of neonatal abstinence syndrome 17 A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? 18 A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected. Which of the following actions is appropriate for nurse to take? 19 A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client’s sibling comes visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time? 20 A nurse is caring for a client following insertion of a subclavian nontunneled percutaneous central venous catheter (CVC). The provider writes a prescription to initiate an IV infusion ringer’s lactate at 150 mL per hr. prior to starting the infusion, which of the following actions should the nurse take? 21 A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrealipase. Which of the following should the nurse include in the teaching? 22 A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose? 23 A nurse on an orthopedic floor is completing morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)? 24 A nurse is caring for a client who has end stage liver disease. The daughter of the client asks about her father’s do-not-resuscitate request. Which of the following is a therapeutic response by the nurse? 25 A nurse is providing teaching to the parent of preschooler who was newly diagnosed with a latex allergy. The nurse should discuss that a cross reaction may occur with which of the following foods? 26 A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is appropriate for the nurse to assignment client to? 27 A nurse has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? 28 A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicate the treatment is effective? 29 A nurse is reviewing medical for four clients. Which of the following represents appropriate documentation? 30 A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse, “does this mean that I must stop nursing my baby?” which of the following is an appropriate statement by the nurse? 31 A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “why did you choose to talk to me out of this room full of kids?” which of the following responses by the nurse is therapeutic? 32 A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room. Which of the following actions should the nurse take first? 33 A client who is precepting a nursing student is brings the following client observation to the nurse’s attention. Which of the following client should the nurse assess first? 34 A nurse is planning teaching for a client who is at 10 weeks gestation and has a history of urinary tract infections (UTIs). Which of the following information should the nurse plan to include in the teaching about UTI prevention? 35 A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24 hr following injury, the nurse should instruct the client to do which of the following? 36 After evaluating the morning laboratory results on several clients, the provider writes prescriptions for four clients assigned to the nurse’s care. Which of the following prescriptions is the nurse’s highest priority? 37 a nurse is caring for a client who has ruptured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds. Which of the following should the nurse take first? 38 A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? 39 A nurse is reviewing morning values of several clients. Which of the following findings is the highest priority for the nurse to report to the provider? 40 A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action? 41 A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis? 42 A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? 43 A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? 44 A nurse is reviewing the history and physical on a client who has right ventricular heart failure. Which of the following is an associated finding? 45 A nurse is assessing a client who has schizophrenia. Which of the following findings indicates a risk for self-harm? 46 A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? 47 A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox Judaism. Which of the following meal suggestions by the newly licensed nurse indicates a need for further teaching? 48 A nurse is preparing to auscultate a client’s apical pulse at the point of maximal impulse (PMI). The nurse should place the diaphragm of the stethoscope at which of the following locations? 49 A charge nurse in the emergency department is reviewing the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibly of child abuse? 50 A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? 51 A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation? 52 A nurse in the postanesthesia care unit is caring for four postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients. 53 A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse initiate first? 54 A visiting nurse is writing a plan of care for a client who is homebound and has stage 2 Alzheimer’s disease. Which of the following should the nurse include in the plan of care? 55 A nurse suspects another nurse is chemically impaired during the shift. Which of the following is an appropriate action for the nurse to take? 56 A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125 mL/hr. Which of the following actions should the nurse plan to take? 57 A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? 58 A nurse is admitting an unidentified female infant who was brought to the emergency department. Based on the assessment findings, the nurse should estimate the infant’s age to be which of the following? 59 A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? 60 A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? 61 A nurse is performing a nutritional assessment on a client who has a calcium deficiency. The nurse should identify that the client is at risk for which of the following? 62 A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding? 63 A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognized as the priority finding? 64 A nurse in a provider’s office is caring or a client who has Parkinson’s disease and has been taking levodopa for the past 5 weeks. The client reports a new onset of muscle twitching. Which of the following statements by the nurse is appropriate? 65 A nurse in the labor and delivery unit is receiving medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? 66 A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? 67 A nurse is planning care for a client who has neutropenia. Which of the following nursing interventions is appropriate to include in the care plan? 68 A nurse is planning to change the dressing on a school age child who has sustained multiple burns. Which of the following actions should the nurse plan to take? 69 An older adult client tells the nurse,” I thought immunizations were for kids.” The nurse informs the client that older adults should receive which of the following immunizations? 70 a nurse is caring for a client who was involuntarily admitted to the psychiatric unit following a failed suicide attempt. The provider prescribes a medication that is part of an experimental treatment. Which of the following actions should the nurse take? 71 A nurse analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? 72 a community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first? 73 a nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? 74 A nurse is assessing a client who is preparing for surgery. The client tells the nurse, “If something happens to me from which I cannot recover don’t want to go on a ventilator.” Which of the following is an appropriate response by the nurse? 75 A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? 76 A nurse is caring for a client who reports pain. Which of the following laboratory findings indicates myocardial damage? 77 a nurse is caring for a client who is prescribed furosemide. The nurse understands this medication is used to treat which of the following client conditions? 78 A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community of which of the following is to generate new ideas to address the public health concern? 79 a nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter? 80 A nurse manager is presenting information to the nursing staff regarding the appropriate use of the client restraints. Which of the following should the nurse include? 81 A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to eh facility. Which of the following clients should the nurse recommend for discharge? 82 A nurse is admitting a client who has chronic gout. The nurse anticipates which of the following provider prescriptions? 83. A nurse is caring for a client who is 2 days postoperative following a lumber laminectomy and is reporting nausea. Which of the following actions should the nurse take first? 84. A nurse in the recovery room is a client who has a new tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify these finding as resulting from which of the following? 85. A nurse is planning for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the assistive personnel AP? 86. An assistive personnel (AP) at a long-term care facility reports to the nurse that another AP has spent the entire morning on the phone and has not completed the morning assignment. Which of the following is an appropriate action by the nurse? 87. A community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house. Which of the following is a priority intervention? 88. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included? 89. A nurse is caring for a client who will be having a transfusion of platelets. The nurse recognizes that the ___ outcome of ____ will be which of the following? 90. A nurse in a prenatal clinic is caring for an adolescent client is now in her third trimester of pregnancy. The nurse identifies that the client is at an increased risk for the which of the following? 91. A nurse is planning dietary intervention for a client who is immobile due to pelvic and femur fractures. Which of the following should the nurse include in the plan? 92. A home health nurse is providing teaching about self-administration of insulin to a client who is newly diagnosed with DM. Which of the following statements by the client a need for further teaching? 93. A school nurse is assessing a child who has scabies. Which of the following is an expected finding? 94. A nurse is caring for a client who is postoperative and at risk for development of DVT. Which of the following should the nurse identify as increasing the risk of developing venous stasis? 95. A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding? 96. A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize ___ this desquamation as an indication of which of the following complications? 97. A nurse is providing education to the mother of a toddler who has pertussis. which of the following statements by the parent indicates the teaching has been effective? 98. A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? 99. A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? pertussis 100. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? 101. A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? 102. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? 103. A nurse in a residential mental health facility is planning care for a new client who has OCD. Which of the following is appropriate for the nurse to include in the plan of care? 104. A nurse delegates tasks to an LPN and AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? 105. A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching? 106. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions by the nurse is appropriate? 107. A nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following information should be included in the teaching? 108. A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the following actions by the client indicates a need for further teaching? 109. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel AP requires the nurse to intervene? 110. A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder cancer. For which of the following finding should the nurse notify the provider? 111. A nurse is providing teaching for the parents of a school-age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, “We are unable to say anything to convince him that ___ is impossible.” Which of the following is an appropriate suggestion? 112. A nurse is taking care of a client who has a diagnosis of HIV. Which of the following client statement should the nurse address first? 113. A nurse is caring for a client who has I left femur fracture is a skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following action is appropriate by the nurse? 114. A nurse educator is discussing about modes of transmission with nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission? 115. A nurse is creating an activity plan for a home-bound older adult client. In the planning the nurse considers the physiologic changes that may affect pulmonary function related to the normal aging process. Which of the following age-related physiologic changes should the nurse consider in the plan? 116. An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? 117. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? 118. A nurse is electronically documenting assessment findings for a client. Which of the following is an example of subjective data? 119. A nurse notice smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? 120. A nurse is caring for a client who has a diagnosis of antisocial personality disorder. The nurse should expect the client to demonstrate which of the following? 121. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 in in duration. Which of the following actions should the nurse take? 122. A nurse is planning care for a child who is unresponsive and increased ICP. Which of the following actions should the nurse take? 123. A nurse is planning care for a client who takes haloperidol ___ the treatment of schizophrenia. Which of the following should the nurse include in the plan of care? 124. A nurse is caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, “Am I dying?” Which of the following actions should the nurse take first? 125. A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? 126. A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurses to facilitate the client’s grief process? 127. A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include in the teaching? 128. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurse to offer as an evening snack? 129. A nurse is admitting an infant who has bacterial meningitis. Which of the following actions should the nurse take first? Administer cefazolin 130. A client asks the nurse if it is safe for him to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? Shellfish allergy 131. A nurse is analyzing the cardiac rhythms of four telemetry clients in the coronary care unit. Identify the rhythm strip that the nurse should recognize as indicative of a client who should be receiving warfarin. rhythm C 132. A nurse in a postpartum unit is caring for several clients. After receiving a change of shifassess first? A client who is 3 days postpartum and has not had a bowel movement since prior to admission 133. A nurse is teaching a family about hospice care. Which of the following appropriate for the nurse to include in the teaching? Hospice care encourages the family to coordinate health care services 134. An infection control nurse is reviewing care procedures for four clients. Which of the following requires the nurse to intervene? A client who has pulmonary TB is placed in a positive pressure room. 135. A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Urine output of 250ml/hr 136. A nurse is providing teaching for the client who has a new prescription for lithium carbonate. Which of the following should the nurse include the teaching? Diarrhea is an indication of toxicity. 137. A nurse is caring for a client who is receiving a blood transfusion at 125ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride IV 138. A nurse is caring for an adolescent client who has no previous history of a seizure disorder___ admitted after having a 3-minn tonic-clonic seizure 2 weeks after sustaining a mild concussion. The client is scheduled to have an electroencephalogram (EEG) in the morning. For breakfast, the client orders coffee and a donut. Which of the following nursing actions is appropriate at this time? Explain that the client may not have coffee prior the EEG 139. At the beginning of the ____ shift, a team leader delegates the following tasks to the assistive personnel (AP) have four clients, distribute fresh water and obtain the morning vital signs. At noon, the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future? Set a clear time from for the completion of each task 140. A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care? Provide the client with an alternating pressure mattress 141. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? Raise the side rails on the bed 142. A nurse is performing postmortem care on an older adult client. Which of the following action is appropriate to take? Lower the head of the bed to a supine position 143. A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of the following actions should the nurse take first? Stabilize the cervical spine 144. A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of TB? Mantoux test 145. A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize? A client who has a Glasgow Coma Score of 4 146. A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings? Pinna below the outer canthus of the eye 147. A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? Restrict dietary calcium intake 148. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following suggestions should the nurse recommend? Eat a bedtime snack containing carbohydrates 149. An immunity health nurse is planning to make home visits to several clients who all live within a few miles’ radius of the office. Which of the following clients should the nurse plan to visit first? A legally blind client who has diabetes mellitus and whose insulin syringes need to be prefilled for the coming week. 150. A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? “Notify your provider if you experience muscle weakness.” 151. A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. difficle. Which of the following action by the nurse is appropriate? Place the client on contact precautions 152. A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo 153. A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set? The client will develop a personalized meal plan. 154. A nurse is caring for a preschool-age child who has a short leg, plaster cast applied 1 hr ago. Which of the following is an appropriate interventions? Support the affected leg on a pillow. 156. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? Consistent contractions last 80 seconds. 157. A home health nurse is reviewing treatment goals with a client who has DM. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? HbA1C 158. A nurse is preparing to obtain informed consent for a colonoscopy from a client who does not speak English. Which of the following actions should the nurse take? Ask the health care interpreter to explain the procedure 159. A nurse manger is presenting an inservice for newly licensed nurses about advance directives. Which of the following statements by a new nurse indicates a need for further teaching? “Advanced directives must be notarized to be legally implemented.” 160. A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? “It communicates y wishes for end-of-life care.” 161. A home health nurse is doing an in-home assessment for an older adult client who is at risk for falls. which of the following assessment findings should the nurse identify as a potential hazard for the client? Electrical cords secured to the baseboards 162. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? Clear fluid drainage from the nares 163. A nurse documents that a client recovering from a closed head injury assumes a decerebrate posture in response to stimuli. Which of the following illustrations indicates this client’s positioning? Posture D 164. A nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse to the postpartum unit? A client who is 2 days postoperative following a colon resection 165. A nurse is caring for a client who has a newly implanted sealed internal radiation devices to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? Maintain the client on bed rest for 72 hr. 166. During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following? Decreases the level of anxiety 168. At the start of the evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Constipation 169. A nurse is discussing the Z-track administration of hydroxyzine hydrochloride with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? “This technique decreases the risk of subcutaneous infiltration.” 170. A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plain of care? Provide high-calorie nutritional supplements. 171. A nurse is evaluating the results of the above urinalysis done for a preschool age child. The nurse should identify that these findings are consistent with which of the following renal disorders? Large albumin Nephrotic syndrome 172. A nurse is preparing to administer vancomycin to a client who has as infected wound. The nurse should plan to __ for which of the following adverse reactions? Ototoxicity 173. A nurse is teaching a client who has a low-literacy level about home management of diabetic mellitus. Which of the following actions is appropriate? Show the client an educational video. 174. A nurse is assessing a client who is 2 hr postoperative following insertion of a chest tube connected to a chest drainage system as depicted in the program above. Which of the following is an expected finding? Fluctuation of the fluid level in chamber “b” 175. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer, the client has two minor children and a limited support system. Which of the following is the priority nursing action? Inform the client of available community resources. 176. A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include? Pain relieved by position change 177. A nurse in a mental health clinic is reviewing the history and physical for a 17-year old client who has a new diagnosis of social phobia. Which of the following is an expected finding? The client reports minimal alteration in performance at a part time job. 178. A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr. Which of the following assessment finding indicates to the nurse that the IV sire needs to be changed? The area around the IV sire is reddened. 179. A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering ___ dose, which of the following laboratory values should the nurse evaluate? Thyroid hormones 180. A nurse is assessing a client who is postoperative3 following abdominal surgery. The client states, “I feel like my incision ripped open,” The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? Place the client in low-Fowler’s position. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? Hepatitis A