CAT 3 KAPLAN (NUR 3465_ Florida National University) Complete (GRADED A) Questions and Answers Provided Exam Study Guide.

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1. The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagec... tomy. Which action will the nurse take first? 1. Place the client on continuous pulse oximetry. 2. Monitor the client for changes in blood pressure. 3. Notify the health care provider. 4. Assist the client to use the incentive spirometer. Ans: 3 2. The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1. Perform hand hygiene frequently. 2. Wear a mask when entering the room. 3. Monitor the roommate for signs of infection. 4. Monitor the amount of protein the client eats. Ans: 1 3. The nurse provides care for a client diagnosed with a bone infection. The client was given intravenous morphine 3 hours ago and cannot have another dose for an hour. The client reports pain that is rated as 6 out of 10. The nurse implements several nonpharmacological approaches. The client’s pain level is now a 3 out of 10. Which action should the nurse take next? 1. Notify the health care provider. 2. Administer the morphine early. 3. Instruct the client that the next dose cannot be given for an hour. 4. Ask the client what an acceptable pain level is. Ans: 4 4. The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client’s plan of care? 1. Client will verbalize a plan to implement a sleep promoting program within the next week. 2. Client will fall asleep with less difficulty over the next 2 weeks. 3. Client will achieve a more normal sleep pattern within 2 to 4 weeks. 4. Client will achieve an improved sense of adequate sleep over the next 4 weeks. Ans: 1 5. The nurse reviews medications prescribed for a client recovering from surgery. Which prescription causes the nurse the most concern? 1. Diphenhydramine 50 mg PO at bedtime, as needed. 2. Furosemide 40 mg IV q.d. 3. Morphine sulfate 2 mg IV every hour, as needed, for pain. 4. Oxygen at 2 L/min via nasal cannula. Ans: 2 6. The nurse reads the result of a tuberculosis (TB) skin test on a client with no known risk factors for TB. Which finding will the nurse interpret as a positive result? 1. Erythema of 5 or more millimeters. 2. Induration of 5 or more millimeters. 3. Induration of 10 or more millimeters. 4. Induration of 15 or more millimeters. Ans: 4 7. The nurse provides care to an older adult client suspected of being a victim of physical abuse. Which action is appropriate for the nurse to implement when providing care to the client? (Select all that apply.) 1. Place the client in a single room near the nurses’ station. 2. Assess the client for bilateral injuries in ankles or wrist. 3. Identify, collect, and preserve physical evidence of abuse. 4. Take photographs to document signs of physical abuse. 5. Use standardized tool to screen for elder mistreatment. Ans: 2, 3, 5 8. A client receiving an enema reports cramping and discomfort when the nurse releases the clamp and places the container 12 inches above the client’s hip level. Which action will the nurse take next? 1. Instruct the client to take deep breaths. 2. Discontinue the enema. 3. Clamp the tubing. 4. Lower the enema bag below the level of the hips. Ans: 3 9. The nurse assesses clients waiting to be seen by the health care provider. Which client does the nurse identify to be seen first? 1. Client with myasthenia gravis reporting double vision and drooping of the right eye lid. 2. Client with a flat 9 mm induration area at the site of a tuberculin skin test placed 48 hours ago. 3. Client with a mean arterial pressure of 80 mm Hg. 4. Client with lung disease reporting dyspnea after walking up stairs. Ans: 2 10. A client experiences wide QRS complexes on telemetry, numbness of the feet, and tingling of both hands. Which medication will the nurse question before administering to this client? 1. Diltiazem. 2. Furosemide. 3. Spironolactone. 4. Metoprolol tartrate. Ans: 3 11. The nurse provides care for a client diagnosed with leukemia. The nurse notes the client has vomited a large amount of bloody emesis. Which action should the nurse take first? 1. Measure the vomitus before dumping it. 2. Assess the client’s last platelet count. 3. Notify the health care provider. 4. Complete a head to toe assessment. Ans: 3 12. The nurse is teaching a client who has undergone a cataract extraction with intraocular implant. Which instruction does the nurse include in the discharge teaching? (Select all that apply.) 1. Avoid activities that require bending over. 2. Place an eye shield on the surgical eye at bedtime. 3. Avoid lifting anything over 5 pounds. 4. Contact the surgeon if eye scratchiness occurs. 5. Take acetaminophen for minor eye discomfort. Ans: 1, 2, 3, 5 13. An infant diagnosed with pertussis is being discharged home with the parents. Which information will the nurse include in the parents’ teaching plan? (Select all that apply.) 1. Hand hygiene using an alcohol-based hand rub is effective against pertussis. 2. Family members and others in close contact with the infant should be vaccinated. 3. Airborne isolation precautions are required for 5 days after the start of antibiotic therapy. 4. Pertussis is most severe for the elderly. 5. Even if a person’s immunization status for pertussis is unknown, it is safe to immunize again. Ans: 1, 3, 5 14. The nurse reviews the care needs for assigned clients. Which client will the nurse assess first? 1. Client with ulcerative colitis who reports rectal bleeding. 2. Client with an acute kidney injury with a urine output of 100 mL over the past 6 hours. 3. Client with angina pectoris who reports a headache after receiving a dose of prescribed nitroglycerin. 4. Client with a radioactive implant for cervical cancer who is in the bathroom. Ans: 4 15. The nurse teaches a client how to self-administer nasal drops. Which statement is part of these instructions? 1. “Occlude one nostril prior to instilling the drops.” 2. “Store the medication vial in the refrigerator between doses.” 3. “Shake the medication vial for several minutes before opening.” 4. “Sit with the neck flexed backward for 5 minutes after instilling the drops.” Ans: 4 16. The nurse assists the code team treating a client with asystole. Cardiopulmonary resuscitation (CPR) is in process. Which direction by the code team leader requires the nurse to intervene? 1. “Push hard and push fast during compressions.” 2. “Give atropine 1 mg followed by an NS flush.” 3. “Give epinephrine 1 mg every 3 to 5 minutes.” 4. “Continue CPR for 2 minutes and then check rhythm.” Ans: 2 17. The nurse provides care to a 10-month-old infant. For which statement made by the parent will the nurse intervene? (Select all that apply.) 1. “My child has a two-word vocabulary.” 2. “My child gained 1 ounce this week.” 3. “My child cannot walk unless I hold under the arms.” 4. “My child cries and spreads the arms in and out when I bump the crib.” 5. “My child’s soft spot on top of the head is still open.” Ans: 2, 4 18. The charge nurse assigns several clients to a novice nurse who is fresh off unit orientation. Which client will the charge nurse assign the novice nurse to provide care during this shift? (Select all that apply.) 1. A client on airborne precautions for newly diagnosed tuberculosis (TB). 2. A client diagnosed with chronic obstructive pulmonary disease (COPD) discharging tomorrow. 3. A client diagnosed with acute pneumonia on a bilevel positive airway pressure (BiPAP) machine. 4. A client status postoperative for a vaginal hysterectomy done earlier in the day. 5. A toddler diagnosed with respiratory syncytial virus (RSV) admitted an hour ago. Ans: 2, 4 19. The nurse teaches a group of nursing students about cultural competency. Which strategy will the nurse include to improve the students' cultural competency? (Select all that apply.) 1. Participate in continuing education classes about culturally congruent care. 2. Develop culturally competent approaches to care. 3. Talk with clients about their cultural views of health. 4. Assess own skill level and seek improvement. 5. Realize that personal preferences can influence the client’s preferences. Ans: 1, 2, 3, 4 20. The nurse manager is concerned about increased instances of client confusion and disorientation in the intensive care unit (ICU). Which nursing intervention is most effective in resolving this issue? 1. Promote daytime periods of sleep. 2. Monitor noise levels during the night. 3. Prioritize and cluster care activities. 4. Turn off TVs and unnecessary lights. Ans: 2 21. The nurse provides care to a client with asthma. Which co-morbid condition does the nurse identify as a trigger for an acute asthma episode? 1. Psoriasis. 2. Cellulitis. 3. Rheumatoid arthritis. 4. Hiatal hernia. Ans: 4 22. The nurse manager creates a discharge teaching form for clients with acquired immunodeficiency syndrome (AIDS). Which statement will the manager include on this form? (Select all that apply.) 1. Avoid children who have just gotten a live vaccine. 2. A condom is necessary during sexual activity. 3. Contact sports, such as football, must be avoided. 4. Drug paraphernalia must not be shared with others. 5. Sexual activity must be restricted to a single partner. Ans: 1, 2, 4 23. The nurse provides pain management teaching to an older adult client diagnosed with osteoarthritis (OA). Which medication does the nurse discuss as the initial treatment of choice for OA pain? 1. Morphine. 2. Acetaminophen. 3. Ibuprofen. 4. Cyclobenzaprine. Ans: 2 24. The nurse prepares teaching materials to review chest physiotherapy with the parents of a pediatric client diagnosed with cystic fibrosis (CF). Which observation indicates to the nurse that additional teaching is needed? (Select all that apply.) 1. Blood pressure 110/68 mm Hg. 2. Pulse oximetry 88% on room air. 3. Respiratory rate 24 breaths/min. 4. Ecchymosis over the back and lateral chest. 5. Complaint of pain with deep inspiration. Ans: 2, 4, 5 25. The nurse receives a verbal prescription from a health care provider (HCP) during a client emergency. Which action does the nurse take to ensure client safety? (Select all that apply.) 1. Record the prescription in the client’s medical record. 2. Read back the prescription to verify the accuracy of the prescription. 3. Date and time the prescription that was issued during the emergency. 4. Record the HCPs prescriber number. 5. Document the nurse’s own name and title. Ans: 1, 2, 3 26. A client in the postanesthesia care unit (PACU) reports nausea to the nurse. Which medication will the nurse given intravenously for this client's problem? (Select all that apply.) 1. Hydroxyzine. 2. Promethazine. 3. Ondansetron. 4. Aluminum hydroxide. 5. Sucralfate. Ans: 1, 2, 3 27. After being notified that a client is seeking legal counsel about care received while hospitalized, the nurse manager investigates a staff nurse’s performance regarding the client’s care. Which nursing action will concern the nurse manager? (Select all that apply.) 1. The nurse mailed prescriptions to the client after discharge. 2. The nurse consulted the wound care nurse for the client’s area of skin breakdown. 3. The nurse found a referral for home care with laboratory results faxed after the client was discharge. 4. The nurse delegated sterile wound care to nursing assistive personnel (NAP). 5. The nurse administered an oral pain medication when an intramuscular dose was prescribed. Ans: 1, 3, 4, 5 28. The nurse provides care for an infant who has a fractured femur. Which statement regarding pain in an infant is accurate? (Select all that apply.) 1. Infants cannot feel pain. 2. Infants cannot express pain. 3. Infants have the same sensitivity to pain as older children. 4. Pain scales do not work well with infants. 5. Absorption of pain medication is faster in an infant than an adult. Ans: 3, 5 29. The nurse provides care for a client diagnosed with new onset atrial fibrillation. The client’s health care provider prescribes a transesophageal echocardiogram (TEE). What reason will the nurse give to the client as the primary reason for performing a TEE? 1. To measure the cardiac index. 2. To rule out thrombus in the heart. 3. To estimate the ejection fraction. 4. To observe ventricular wall motion. Ans: 2 30. The nurse provides care for a pediatric client suspected of having the respiratory syncytial virus (RSV). Which transmission-based precaution does the nurse initiate once influenza and adenovirus are ruled out for this client? 1. Airborne precautions. 2. Droplet precautions. 3. Reverse precautions. 4. Contact precautions. Ans: 4 31. The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply.) 1. Consume a diet low in saturated fat. 2. Engage in regular, high-intensity aerobic activity. 3. Stop tobacco use by any possible means. 4. Avoid exposure to second-hand smoke. 5. Consume a diet low in soluble fiber. Ans: 1, 3, 4 32. The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request. 2. Make the accommodation. 3. Advocate for modification of the organization’s dress code. 4. Review the organization’s dress code policy. Ans: 4 33. The nurse provides care for a client diagnosed with insomnia. Which intervention does the nurse include in the nursing care plan? 1. Encourage afternoon naps. 2. Provide dairy products 30 minutes before bedtime. 3. Advise the client to vary retire and awake times. 4. Limit naps to less than 60 minutes. Ans: 2 34. The nurse is proving care for several clients. Which client need will the nurse address first? 1. Client with a stroke needing a hand splint reapplied. snack. 2. Client with diabetes and a fasting blood glucose of 78 mg/dL requesting a 3. Client with diarrhea needing the bedside commode emptied. 4. Client with emphysema requesting assistance with ambulation. Ans: 4 35. The nurse provides care to a newly admitted client. At which time will the nurse conduct a medication reconciliation? (Select all that apply.) 1. At every clinic appointment. 2. At the pharmacy. 3. Upon discharge to home. 4. Upon entry into the unit. 5. Upon transfer to a skilled unit. Ans: 1, 3, 4, 5 36. The nurse provides care for a client experiencing a fever who also reports bone pain, redness, and swelling. The client asks the nurse which treatment will likely be prescribed by the health care provider (HCP). Which response from the nurse is the most accurate? 1. “Usually a few days of bed rest and antibiotics are needed.” 2. “You will need surgery and then antibiotics for a few weeks.” 3. “Antibiotics will be prescribed for several weeks, which you can take at home.” 4. “If the area improves with rest and warm compresses, you might just need pain medication.” Ans: 3 37. The nurse assesses a newborn. Which finding alerts the nurse that the newborn is at risk for hyperbilirubinemia? 1. Caput succedaneum. 2. Hyperglycemia. 3. Petechiae. 4. Cephalhematoma. Ans: 4 38. Which safety measure is appropriate for the nurse to use to prevent the development of a pressure injury when providing care to clients? (Select all that apply.) 1. Encourage dorsiflexion exercises of the foot. 2. Limit the client’s intake of caffeinated fluids. 3. Encourage the client to hold the breath and try to exhale when moving up in bed. 4. Use a turning or lift sheets or devices to turn or transfer clients. 5. Avoid a strong massage over bony prominences. Ans: 4, 5 39. A client sues the nurse and the hospital for malpractice. Which resource will the nurse refer to determine if the client’s suit is legitimate? 1. Medical record. 2. Standards of care. 3. American Nurses Association Code of Ethics. 4. The Joint Commission standards. Ans: 2 40. A client who takes alendronate asks the nurse when the medication can be stopped. Which response by the nurse is best? 1. “People usually have to take this medication for a few months.” 2. “Unfortunately, you will need to take this medication for the rest of your life.” 3. “After a few doses, the frequency and need to take this medication will be reevaluate” 4. “A scan will be repeated in 3 years, and if your bone mass stabilizes, it can be discontinued.” Ans: 4 41. The nurse provides care for a client admitted to the hospital for an ischemic cerebrovascular event. The nurse is scheduled to administer clopidogrel, aspirin, and dexamethasone to the client. Which action should the nurse take? (Select all that apply.) 1. Send a stool specimen to the hospital laboratory to test for occult blood. 2. Ask the client if there is any history of gastrointestinal bleeding or stomach ulcers. 3. Administer the medications and write a note documenting the nurse’s concern. 4. Hold the medications until the health care provider is expected to visit the client. 5. Notify the health care provider that the client is at risk for a medication interaction. Ans: 2, 5 42. While conducting an abdominal assessment the nurse palpates a small round mass above the client’s symphysis pubis. Which action will the nurse take first? 1. Auscultate the mass. 2. Ask the client to void. 3. Apply pressure to the mass. 4. Ask if the client is experiencing pain. Ans: 2 43. The nurse receives report on assigned clients. Which client will the nurse assess first? 1. Client who had a myocardial infarction 3 hours ago and is experiencing two to three premature ventricular contractions per minute. 2. Client who had a lumbar puncture 2 hours ago and is reporting a headache rated as an 8 on a pain rating scale of 0 to 10. 3. Client who had a permanent pacemaker inserted 12 hours ago and is reporting dizziness. 4. Client who had a total hip replacement 8 hours ago and is in a semi- Fowler position. Ans: 3 44. A nurse works to establish a nurse-client relationship with a client who is new to the mental health unit. Which task does the nurse perform during the introductory phase of the nurse-client relationship? (Select all that apply.) 1. Discuss confidentiality with the client. 2. Assist the client to explore feelings. 3. Clarify the client’s problem. 4. Summarize the client’s success. 5. Identify the tasks the client should accomplish. Ans: 1, 3, 5 45. The nurse provides care for a client who reports a lack of appetite, nausea, and passing a small amount of liquid stool throughout the day for several days. Which action does the nurse do next? 1. Administer prescribed medication for constipation. 2. Consult with the dietitian regarding client’s diet. 3. Perform a digital rectal exam. 4. Obtain a stool sample from the client. Ans: 3 46. While assessing an adolescent for a sore throat and fatigue, the nurse notes multiple wounds in different levels of healing on both of the client’s arms. Which action will the nurse take first? 1. Inquire as to how the wounds occurred. 2. Ask about a history of sexual abuse. 3. Assess the wounds for healing and signs of infection. 4. Report the findings to the nursing supervisor. Ans: 3 47. The nurse performs triage at a mass casualty incident. Which client will the nurse recommend receive treatment first? 1. Adolescent client with abdominal bleeding and confusion. 2. School-aged child with lacerations on the face and scalp. 3. Older adult client with a chest wound who is apneic. 4. Adult client with an open fracture of the humerus with present radial pulses. Ans: 1 48. A female client received 2 units of packed red blood cells (PRBCs) for gastrointestinal bleeding. Which finding indicates to the nurse that the client may need an additional transfusion? (Select all that apply.) 1. Pulse rate 115 beats/minute. 2. Blood pressure 82/40 mm Hg. 3. Hemoglobin 13 g/dL (130 g/dL). 4. Hematocrit 28%. 5. Red blood cell count 4 X 106 cells/µL (4.4 X 1012 cells/L). Ans: 1, 2, 4 49. The nurse notes the client’s electrocardiogram (ECG) rhythm is torsades de pointes. Which assessment does the nurse complete after a normal sinus rhythm is restored? 1. Monitor for ST segment depression. 2. Monitor for QT interval prolongation. 3. Monitor for PR interval prolongation. 4. Monitor for narrow QRS complexes. Ans: 2 50. The nurse manager reviews the importance of using best evidence when planning client care during a nursing staff meeting. Which nursing staff response indicates additional information is required regarding evidence-based practice? (Select all that apply.) 1. “I’m glad that standardized care plans are gone.” 2. “Care plans now will be customized and useful.” 3. “I always liked research and now we can do it with our clients.” 4. “A software program to help search for information will be helpful.” 5. “Now we know that interventions for care will work for our clients.” Ans: 1, 3 51. A client receiving a blood transfusion develops a cough, rales in bilateral lower lung lobes, shortness of breath, and restlessness. Which action will the nurse take? (Select all that apply.) 1. Slow down the blood transfusion. 2. Place client on the left side. 3. Apply oxygen. 4. Administer prescribed furosemide. 5. Monitor vital signs every 2 to 4 hours. Ans: 1, 3, 4 52. The nurse creates a care plan for a client diagnosed with bilateral lower lobe pneumonia. Which intervention is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Instructing the client on the importance of increasing fluid intake. 2. Assisting the client to a high-Fowler position when in bed. 3. Encouraging the client to not talk when receiving a nebulizer treatment. 4. Reminding the client to use the incentive spirometer every hour when awake. 5. Encouraging the client and family to wash their hands frequently. Ans: 2, 3, 4, 5 53. The nurse provides cares for a client with a sodium level of 156 mEq/L (156 mmol/L). Which health care provider prescription does the nurse anticipate? 1. A 3% saline solution. 2. A 5% dextrose solution. 3. A 0.9% saline solution. 4. A lactated ringer solution. Ans: 2 54. The nurse provides care for a client who just returned from total hip arthroplasty with a gravity drain. Which type of drainage does the nurse expect to find in the gravity drain? 1. Sanguineous. 2. Serous. 3. Purulent. 4. Serosanguineous. Ans: 1 55. The nurse is discussing infection control guidelines with a group of student nurses. Which information is most important for the nurse to include in the teaching? (Select all that apply.) 1. “Gloves should be removed before the protective gown is removed.” 2. “Glove cuffs are pulled up over the gown cuffs.” 3. “Perform hand hygiene before gloving and immediately after removing the gloves.” 4. “The needle should not be recapped after withdrawing medication from a vial.” 5. “Gloves should be worn when measuring the blood pressure of a client who has tested positive for the human immunodeficiency virus (HIV).” Ans: 1, 2, 3 56. The nurse provides care for a newborn client in the nursery. Which sign indicates to the nurse that the client is experiencing neonatal hypoglycemia? (Select all that apply.) 1. Hyperthermia. 2. Poor feeding. 3. Jitteriness. 4. Hypertonia. 5. Seizures. Ans: 2, 3, 5 57. A client reports receiving injuries from falling down the stairs yet avoids looking at the nurse when asked about a left eye bruise. Further questions are answered only after glancing at the spouse and with the words yes or no. Which action will the nurse take first? 1. Report the spouse to the nursing supervisor for abuse. 2. Ask the client how the fall down the stairs occurred. 3. Ask the client for a urine specimen to be collected in the presence of the nurse. 4. Ask the client if the head was also injured in the fall. Ans: 3 58. The nurse teaches a parent measures to reduce her school-age client’s fever. Which information does the nurse include? 1. Sponge the skin with cold water. 2. Give aspirin for a fever of 100.4° F (38° C) or higher. 3. Cover with warm blankets. 4. Apply clothing lightly. Ans: 4 59. A nursing unit is short-staffed. The nurse provides care for several more clients than usual. The nurse uses the triage principle to best distribute the nursing care. Which ethical principle will the nurse use in this situation? 1. Beneficence. 2. Justice. 3. Nonmaleficence. 4. Fidelity. Ans: 2 60. The nurse provides care for a client who is diagnosed with diabetic ketoacidosis. The health care provider prescribes an intravenous (IV) insulin infusion. Which action does the nurse implement when administering the infusion? (Select all that apply.) 1. Monitor blood glucose levels every 4 hours. 2. Prepare the infusion of 100 units of intermediate-acting insulin in 100 mL normal saline solution. 3. Discontinue the insulin infusion as soon as blood glucose levels decrease. 4. Monitor potassium level closely. 5. Administer the insulin infusion via an electronic infusion device. Ans: 4, 5 61. A client suddenly develops anxiety, dyspnea, and tachypnea immediately after central venous access device (CVAD) insertion. The nurse determines that which complication is the most likely cause of the client’s distress? (Select all that apply.) 1. Air embolism. 2. Pneumothorax. 3. Pulmonary edema. 4. Heart failure. 5. Cardiac tamponade. Ans: 1, 2 62. The nurse provides care for a client in the post-operative anesthesia care unit (PACU) who had an open reduction for a hip fracture. Which nursing diagnosis is the highest priority? 1. Anxiety. 2. Risk for Infection. 3. Acute pain. 4. Delayed surgical recovery. Ans: 3 63. The nurse provides care for a client with sealed radiation implants to treat uterine cancer. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Keep the client’s door open to prevent isolation. 2. Place a dosimeter film badge on the client’s gown. 3. Restrict visitors less than 16 years of age. 4. Keep long-handled forceps in the client’s room. 5. Limit each visitor to no more than 30 min per day. Ans: 3, 4, 5 64. The nurse prioritizes care for a group of clients after receiving hand-off communication. Which client does the nurse see first? 1. An older adult client with pneumonia requiring intravenous access for the next dose of antibiotics. 2. A middle-age adult client with urinary retention who has not voided for 8 hours. 3. A middle-age adult client receiving morphine by patient-controlled analgesia with a respiratory rate of 12 breaths/min. 4. An older adult client with confusion identified as being at risk for falling. Ans: 3 65. The nurse performs medication reconciliation for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which class of medication does the nurse question because of possible adverse effects in clients with COPD? 1. Anticoagulants. 2. Benzodiazepines. 3. Loop diuretics. 4. Angiotensin converting enzyme inhibitors. Ans: 2 66. The nurse assesses the respiratory status of a 12-hour-old newborn. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Nasal flaring. 2. Acrocyanosis. 3. Tachypnea. 4. Ten second periods of apnea. 5. Respiratory rate of 40 breaths per minute. Ans: 1, 3 67. The nurse reviews a list of pregnant clients waiting to be seen in an antepartum clinic. Which client will the nurse recommend that the health care provider see first? 1. Client at 10 week's gestation reporting urinary frequency. 2. Client at 17 weeks' gestation reporting no fetal movement. 3. Client at 25 weeks' gestation reporting shortness of breath with walking. 4. Client at 37 weeks' gestation reporting nocturia. Ans: 3 68. The nurse delegates care of a client at risk for venous thromboembolism to the LPN/LVN. Which action by the LPN/LVN causes the nurse to intervene? (Select all that apply.) 1. Reinforce the need to flex and extend legs and feet every 2 hours with the client. 2. Apply sequential compression devices to the client. 3. Administer enoxaparin 80 mg subcutaneously to the client. 4. Teach the client the symptoms of pulmonary embolism. 5. Administer oral norgestimate-ethinyl estradiol to the client. Ans: 4, 5 69. The nurse provides care for a client diagnosed with aphasia. Which action does the nurse implement when communicating with this client? (Select all that apply.) 1. Have family members translate for the client as needed. 2. Ask questions that can be answered by “yes” or “no.” 3. Decrease environmental stimuli that might be distracting. 4. Allow body contact such as clasp of hand or touching. 5. Provide the client with simple recorded instructions. Ans: 2, 3, 4 70. The nurse instructs a client about a low-fat, high-fiber diet. Which food does the client chose that best indicates an understanding of the low-fat, high-fiber diet? 1. Garden salad with hard-boiled eggs and Italian dressing. 2. Vegetable stock soup with vegetables served with oat bread. 3. Tuna salad sandwich with celery on whole wheat bread. 4. Broiled chicken stuffed with chopped apples and walnuts. Ans: 2 71. The nurse provides care for a 12-month-old infant. The infant’s parent states to the nurse, “My baby sleeps 18 hours a day; 14 hours at night and a 4-hour nap.” Which action does the nurse take next? 1. Let the parent know this is normal for the infant’s age. 2. Instruct the parent to cut back on the time the infant naps. 3. Notify the health care provider. 4. Instruct the parent to put the infant to bed earlier at night. Ans: 3 72. The nurse provides care for a client who begins nutritional therapy with parenteral nutrition. The client reports feeling anxious and restless. Which action does the nurse take to prevent the client from being injured? 1. Secure all connections in the system. 2. Monitor vital signs every two hours. 3. Calculate intake and output every four hours. 4. Check blood glucose levels every four hours. Ans: 1 73. The nurse administers a regular insulin intravenous (IV) infusion for a client diagnosed with diabetic ketoacidosis (DKA). Which finding indicates to the nurse that the client is experiencing complications from the insulin infusion? (Select all that apply.) 1. Blood glucose of 66 mg/dL (3.6 mmol/L). 2. Increased urine output. 3. Sodium of 148 mEq/L. 4. Altered mental status. 5. Potassium of 3.0 mEq/L. Ans: 1, 4, 5 74. The nurse assesses the respiratory status of 6 newborns. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Respirations 38 breaths per minute at 30 minutes of age. 2. Six-second periods of apnea at 1 hour of age. 3. Grunting at 20 minutes of age. 4. Nasal flaring when the infant is supine. 5. Abdomen and chest rise together for each breath. Ans: 3, 4 75. The nurse plans the discharge of a client recovering from an ischemic stroke. Which core measure needs to be met for this client? (Select all that apply.) 1. Provide a prescription for a statin medication at discharge. 2. Refer the client for psychotherapy at discharge. 3. Meet goals for nutrition within 1 week. 4. Provide and document stroke education prior to discharge. 5. Prevent venous thromboembolism. Ans: 1, 4, 5 76. Which activities can the nurse delegate to the nursing assistive personnel (NAP) for client in the post anesthesia unit (PACU)? (Select all that apply.) 1. Obtaining vital signs 2. Assisting with positioning 3. Suctioning the oropharynx 4. Accompanying client transfer 5. Measuring urine output Ans: 1, 2, 4, 5 77. The nurse provides care for a client experienced major head trauma. The client is scheduled to receive a bolus enteral feeding. Which is the most important action the nurse takes? 1. Measure intake and output 2. Monitor blood glucose levels 3. Check albumin level 4. Monitor for diarrhea Ans: 1 78. The nurse provides care for a client diagnosed with itractable pain. The client is prescribed magnesium sulfate 2 mg intravenous push (IVP) now and every 4 to 6 hours, PRN for pain. Which action should the nurse take first? 1. Administer the medication 2. Insert an intravenous access device 3. Question the prescribed medication 4. Assess pain level using a numeric rating scale Ans: 3 79. The nurse receives a call from the emergency department (ED) stating the need to transfer a client with suspected tuberculosis (TB) to the unit. This unit is not equipped with a negative airflow pressure room. What action does the nurse take? 1. Advise the ED that they need to hold the transfer until the nurse speaks with the nursing supervisor. 2. Advise the ED that the nurse cannot take the client because the nurse does not have the proper equipment. 3. Contact the client’s health cate provider. 4. Proceed with the transfer, ensuring the client has a private room and all staff wear N-95 masks. Ans: 1 80. The receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client? 1. Administer as a rectal suppository. 2. Administer with a glass of milk or antacid 3. Give sublingually, times three doses 4. Have the client chew non-enteric coated ASA Ans: 4 81. The nurse instructs a client on advance directives. Which client statement indicates to the nurse need for further education? 1. Advance directives should be completed long before a medical crisis develops. 2.I decide who will make health care decisions for me if I chose a Health Care Proxy." 3. A living will means my family will know what life-sustaining measures I want taken. 4. A power of attorney for health care prevents my children from selling my home. Ans: 4 82. The nurse performs preoperative assessment on a client scheduled for aortic valve replacement surgery. Which finding causes the most concern? (SATA): 1. Report of allergies to bananas, kiwi, and avocados 2. History of rash on hands that’s lasted more than 1 week 3. High pitched diastolic murmur present on auscultation 4. Report of weakness that occurs with activity 5. History of swelling, itching, and hives after contact with a balloon. Ans: 1, 2, 5 83. The nurse provides care for a client who reports not having a stool for 4 days. The nurse checks the client’s rectum and finds a ball of hard faces about 4 inches about the rectum. Which action does the nurse take next? 1. Administer an oil retention enema 2. Digitally remove the stool 3. Have the client sit on the toilet to attempt to defecate 4. Administer an oral stool softener Ans: 1 84. The nurse provides care to a client diagnosed with bulimia nervosa. Which sign will the nurse expect to observe while providing care to this client? (SATA): 1. Hypernatremia 2. Tooth erosion 3. Parotid gland swelling 4. Gastric narrowing 5. Hypokalemia Ans: 2, 3, 5 85. The nurse reviews care needs for group of clients. Which activity does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Reinforce the dressing of a with a pressure injury 2. Monitor the vital signs of a client who had myocardial infarction 12 hours ago, and being transferred from the coronary care unit 3. Administer a presented tap water enema to a client scheduled for a colonoscopy in 2 hours 4. Assist a client who had an above the knee amputation 40 hours ago into a prone position 5. Help a client who had a colon resection 36 hours ago to ambulate Ans: 4, 5 86. The nurse reviews a list of pregnant clients waiting to be seen in an antepartum clinic. Which client will the nurse recommend that the health care provider see first? 1. Client at 10 week’s gestation reporting urinary frequency. 2. Client at 17 weeks’ gestation reporting no fetal movement 3. Client at 25 weeks’ gestation reporting shortness of breath with walking 4. Client at weeks’ gestation reporting nocturia Ans: 3 87. The nurse asses the respiratory status of 6 newborns. Which finding does the nurse report to the health care provider? (SATA): 1. Respirations 38 breaths per minute at 30 minutes of age 2. Six- second periods of apnea at 1 hour of age 3. Grunting at 20 minutes of age 4. Nasal flaring when the infant is supine 5. Abdomen and chest rise together for each breath Ans: 3, 4 88. The nurse provides care for a client who is severely withdrawn. Which medication will the nurse expect to be prescribed for this client: 1. Lorazepam 2. Chlordiazepoxide 3. Phenytoin 4. Citalopram Ans: 4 89. A client asks for an explanation about advances directives. Which entity should the nurse include in the response to this client? (SATA) 1. Living will 2. Health care proxy 3. Organ donor card 4. Hospice benefit guide 5. Do-not-resuscitate prescription Ans: 1, 2, 5 90. The charge nurse observes a client care provided by staff members. Which observation will the nurse immediately intervene? (SATA): 1. Speech-language pathologist offers a post-cerebral vascular accident (CVA) client thickened liquid from a spoon. 2. Health care provider uses a personal stethoscope to asses a client with pneumonia caused by Acinetobacter. 3. Nursing assistive personnel (NAP) changes bed linen while the client with Meniere disease ambulates to the bathroom 4. LPN/LVN gathers normal saline, blood tubing, and premedication for a client going to receive a blood transfusion 5. Nurse leaves a client’s room and enters another before performing hand hygiene Ans: 2, 3, 5 91. The nurse provides care to a client receiving mechanical ventilation for 4 days. Which action will the nurse use to prevent ventilator-associated pneumonia (VAP)? Select all that apply: 1. Change the ventilator tubing once a shift 2. Elevate the head of the bed 30 to 45 degrees 3. Wear a surgical mask during suctioning 4. Perform daily spontaneous breathing trials 5. Drain condensation from the ventilator tubing Ans: 2, 4, 5 92. The nurse assesses a client diagnosed with heart failure. The nurse’s findings include a heart rate of 126 beats/min and an altered level of consciousness. Which action should the nurse take next? 1. Assess the clients for jugular distention 2. Evaluate the client’s peripheral pulses 3. Administer the prescribed diuretic medication Notify the health care provider of the status change Ans: 1 93. A client with benign prostatic hyperplasia has a postvoid residual volume of 200 mL. Which medication will the nurse expect the health care provider to prescribe for this client? 1. Alfuzosin 2. Tolterodine 3. Dutasteride 4. Amitriptyline Ans: 1 94. The nurse provides care for a client diagnosed with colon cancer. The clioent is scheduled to have an endoscopy, a PET scan and an MRI. The client questions the nurse as to why all these tests are necessary Which response by the nurse is best? 1. The tests serve to obtain a 3-dimensional view of the tumor. 2. The tests help the provider gather detailed tumor information 3. The provider can use the tests to determine the grade of the tumor cells. 4. The provider will use the tests to decide if chemotherapy will be helpful. Ans: 2 95. The nurse provides care for a client who requests testing for human immunodeficiency virus (HIV). Which intervention is most important for the nurse to perform before administering testing? 1. Discuss prevention practices to prevent the transmission of HIV to others. 2. Explain that all tests must be repeated twice to be valid. 3. Ask the client to identify all sexual partners. 4. Determine when the client thinks the exposure to HIV occurred. Ans: 4 96. The nurse provides care for a client with a platelet count 38,000. Which actions are appropriate for the nurse to take? (Select all the apply) 1. Give prescribed Vitamin B12 IM. 2. Monitor neurologic changes every 4 hours 3. Perform chest physiotherapy twice daily. 4. Apply firm pressure to venipuncture sites. 5. Keep pathways and bedside uncluttered. Ans: 2, 4, 5 97. The nurse assesses a newborn to determine gestational age. Which finding does the nurse document as a characteristic of a post-term neonate? 1. Slow recoil of the pinna. 2. Skin that is cracked and peeling. 3. Absent vernix. 4. Deep plantar creases. 5. Lanugo present on the extremities. Ans: 2, 3, 4 98. The nurse notes that a toddle- age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next? 1. Document the findings in the chart. 2. Talk to the nursing supervisor. 3. Ask the client what happened. 4. Discuss the findings with the health care provider. Ans: 2 99. The nurse teaches a client about how yoga can control pain. Which client statement indicates to the nurse that the client understands the teaching? 1. “ I will learn how to visualize images that can help me relax” 2. “I will learn how to perform exercises to improve my circulation” 3. “ I will learn to control my physiological responses to pain.” 4. “ I will use to sound to help relieve my distress.” Ans: 2 100. The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply) 1. Place respiratory equipment at the bedside. 2. Remove harmful objects from the clients reach. 3. Apply foam padding around the bed rails. 4. Time the duration of seizure activity. 5. Teach the client about antiseizure meds. Ans: 1, 2, 3 101. The health care provider prescribes a unit of PRBCs for a client admitted with lower gi bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1. Ensure adequate infusion access is present before obtaining the blood from the blood bank. 2. Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator. 3. Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4. Monitor the client closely during the first 15 to 30 minutes of administration. 5. Ensure the administration time does not exceed 6 hours. Ans: 1, 3, 4 102. The nurse cares for a client scheduled for surgical repair of a hiatal hernia next month. Which intervention should the nurse suggest that the client implement? (Select all that apply.) 1. Avoid chocolate and carbonated drinks. 2. Wear abdominal binder during the day. 3. Stay in an upright position after meals. 4. Increase fluid intake in the evening. 5. Elevate the head of the bed six inches. Ans: 1, 3, 5 103. A client reports having chest irradiation as a child for non-hodgkin lymphoma (NHL). On which potential adulthood complication will the nursee focus when assessing this client? 1. Chronic infertility 2. Asthmatic bronchitis 3. Hodgkin Lymphoma 4. Lung cancer Ans: 3, 4 104. The nurse notes that the last immunization a 15- year old client received was at age 6. Which vaccine will the nurse administer to the client? (Select all that apply.) 1. Varicella Vaccine (VAR) 2. Influenza vaccine (LAIV) 3. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) 4. Pneumococcal conjugate vaccine (PCV13). 5. Human Papilloma Vaccine (HPV) Ans: 2, 3, 5 105. A nursing unit is short-staffed. The nurse provides care for several more clients than usual. The nurse uses the triage principle to best distribute the nursing care. Which ethical principle will the nurse use in the situation? 1. Beneficence 2. Justice 3. Nonmaleficence 4. Fidelity Ans: 2 106. The nurse notes that a client is prescribed sevelamer. Which action will the nurse take when providing the client with a dose of the medication? 1. Remind to chew the medication. 2. Ask to drink a full glass of water. 3. Inquire about an allergy to shellfish. 4. Provide with a meal. Ans: 4 107. The nurse notes these findings in a newborn: skin smooth and transparent, abundant lanugo on back, slow recoil pinna, and absent plantar creases. When planning care, the nurse will assess the newborn for which condition? 1. Subinvolution 2. Hyperglycemia 3. Postmaturity syndrome 4. Respiratory distress syndrome Ans: 4 108. The charge nurse notes that a client is seen in the emergency department (ED) for the third time in 5 weeks. The client has a history of chronic respiratory disorder and diabetes mellitus. The client’s record lists multiple home addresses and no family. The client indicates a lack of employment. Which referral is most appropriate for this client? 1. Hospital social worker. 2. Community housing. 3. Case manager 4. County welfare program Ans: 3 109. The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request 2. Make the accomodation 3. Advocate for modification of the organization’s dress code. 4. Review the organization’s dress code policy Ans: 4 110. The nurse provides care for a client preparing to go to sleep. The client states to the nurse “ I just can’t relax, and I don’t want to take any sleep medication. What else can I do?” Which action by the nurse can help promote relaxation for sleep? (Select all that apply) 1. Provide a large snack with warm milk. 2. Remove the wrinkles from the bed linen. 3. Provide a backrub. 4. Reposition the client. 5. Provide extra pillow. Ans: 2, 3, 4, 5 111. The nurse suspects that a client with a head injury is developing Cushin triad. Which finding causes the nurse to make this clinical determination? (Select all that apply) 1. Resp rate 20 breaths/min 2. Pulse oximeter 92% 3. Pulse 52 beats/min and irregular. 4. Temperature 98.4 F 5. Blood pressure 180/58 mm Hg Ans: 3, 5 112. The nurse triages a client suspected of having meningococcal meningitis. Which action does the nurse next in the provision of care? 1. Perform hand hygiene 2. Apply surgical mask 3. Move the client to a negative pressure room. 4. Check the client for nuchal rigidity. Ans: 2 113. The nurse provides care for a client who had a splenectomy 2 days ago. The nurse is also assigned a client diagnosed with pneumoccocal pneumonia. Which action should the nurse take first? 1. Place the splenectomy client in reverse isolation. 2. Ensure that both clients receive broad- spectrum antibiotics 3. Request the charge nurse after the client care assignment. 4. Maintain strict aseptic technique while providing client care. Ans: 3 114. Upon arriving to the operating room suite, a client tells the nurse that no one provided a paper for the client to sign that gives permission to complete the surgery. Which action will the nurse take first? 1. Explain the surgical procedure to the client. 2. Ask the client to sign the consent form now. 3. Determine if preoperative meds were given to the client. 4. Notify the HCP that a consent form has not been assigned. Ans: 3 115. While performing an eye assessment, a client asks the nurse what the reason for vision could be to be blurry when looking straight ahead. For which health problem will the nurse perform an additional assessment? 1. Cataracts 2. Glaucoma 3. Detached retina 4. Macular degeneration Ans: 4 116. The nurse plans the discharge of a client recovering from an ischemic stroke. Which core measure needs to be met for this client? (Select all that apply) 1. Provide a prescription for a statin medication at discharge. 2. Refer the client for psychotherapy at discharge 3. Meet goals for nutrition within 1 week. 4. Provide and document stroke education prior to discharge Ans: 1, 3, 4 117. The nurse provides care for a client who begins nutritional therapy with parenteral nutrition. The client reports feeling anxious and restless. Which action does the nurse take to prevent the client from being injured? 1. Secure all connections in the system 2. Monitor vitals q 2 hrs 3. Calculate intake and output ever four hours 4. Check blood glucose levels every four hours Ans: 1 118. The nurse provides care for a client diagnosed with asthma. The client is prescribed albuterol and beclomethasone metered dose inhalers. Which client action indicates to the nurse that further teaching Is needed? 1. Using a spacer with both inhalers. 2. Rinsing the mouth after taking the beclamethasone metered dose inhaler. 3. Writing down how many doses have been taken from the metered dose inhaler. 4. Using the beclomethasone inhaler, waiting 5 minutes, then taking the albuterol inhaler. 5. Placing the inhaler directly to the lips when administering the dose without a spacer. Ans: 4, 5 119. The nurse is caring for a client admitted with a COPD exacerbation. Which finding would require immediate attention from the nurse? (Select all that apply) 1. Decreased expiratory peak flow meter readings. 2. Evidence of finger clubbing 3. Increased anterior posterior chest diameter 4. Change in sputum color and amount 5. Presence of fever and tachycardia. Ans: 1, 4, 5 120. The nurse assesses a 4-hour old newborn for acrocyanosis. Which finding does the nurse expect? (Select all that apply) 1. Blue extremities rated “1” for color on Apgar score. 2. Cyanosis of the trunk and thoracic region 3. Cyanosis of the hands and feet. 4. Color returns quickly after blue area is blanched. 5. Cyanosis of the lips and mucous membranes. Ans: 1, 3, 4 121. The nurse supervises the care of clients diagnosed with dehydration. Which client does the nurse delagate to the LPN/LVN? 1. Client with hemoglobin decreased from 18 to 14 2. Client with urine specific gravity decreased from 1.040 to 1.035 3. Client with serum sodium level increased from 149 meq to 155 4. Client with bUN level increased from 24 to 30 Ans: 1 122. The nurse provides care to an older adult client in the hospital. Which factor increases this client’s risk of falling? (Select all that apply) 1. Glare from bright lights 2. HTN 3. Obesity 4. Medication interactions 5. Previous falls Ans: 1, 4, 5 123. The nurse provides care to a client with a neutrophil count of 1000 cells/mm^3 (1 x 109/L). Which intervention will the nurse include in the clients care plan? (Select all that apply) 1. Check gums for bleeding. 2. Omit uncooked foods from the diet 3. Check temp every 4 hours 4. Drink only bottled water 5. Microwave on high when reheating food Ans: 2, 3, 4 124. A client who is pregnant is prescribed a medication that is pregnancy category D. Which statement does the nurse make to the client when explaining this drug category? 1. Studies indicate adverse effects in animal fetuses, but human fetuses are unknown 2. Studies indicate that a possible fetal risk in humans has been reported 3. Studies indicate fetal abnormalities have been reported 4. Studies indicate no risk to animal fetuses, but human fetuses are unknown Ans: 2 125. The nurse provides care for a client diagnoses with an acute sickle cell crisis. Which clinical manifestation should the nurse expect to observe in the client during the shift assessment? (Select all that apply) 1. Weakness 2. Acute pain 3. Flushing of the skin 4. Erectile dysfuntion 5. Joint swelling Ans: 1, 2, 5 126. A nurse provides care for an adult client in the hospital. The caretaker from the client’s agency is at the bedside. The client voices concern about consenting to an elective surgery. The caretaker states, “Just sign the papers and stop acting like such a baby”. Which response by the nurse is the most appropriate? 1. Reassure the client about the surgery 2. Notify the surgeon of the client’s feelings. 3. Ask the caretaker to not berate the client 4. Answer the client’s questions about the surgery. Ans: 2 127. The nurse provides care to a client prescribed long-term prednisone for the treatment of COPD. Which side effect of prednisone does the nurse expect to observe? (Select all that apply) 1. Loss of appetite 2. K+ 3.1 3. Weight loss 4. Blood sugar 180 5. BP 140/90 Ans: 2, 4, 5 128. The nurse learns that a client has no running water or electricity in the home. Which action will the nurse take when advocating for this client? 1. Contact the utility companies 2. Notify the local fire department 3. Assist to relocate to a homeless shelter 4. Provide skilled nursing facility information Ans: 1 129. The nurse provides care to a client with a tracheostomy. Which nursing action performed before the client eats poses a risk to the client? 1. Deflate the tracheostomy cuff 2. Provide thin liquids 3. Suction the trach 4. Raise head of the bed Ans: 2 130. The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply) 1. Consume a diet low in saturated fat. 2. Engage in regular, high intensity Aerobic activity. 3. Stop tobacco use by any possible means 4. Avoid exposure to secondhand smoke 5. Consume a diet low in soluble fiber Ans: 1, 3, 4 131. The nurse prepares to insert a rectal tube in a client experiencing severe abdominal pain from flatus. Which approach does the nurse use when inserting this device? 1. Tape the tube in place for 30 mins 2. Insert the tube 2-4 inches past both the anal sphincters 3. Place the client in the right lateral recumbent position 4. Lubricate the tube with an oil-based lubricant Ans: 2 132. The nurse determines that a client’s condition is deteriorating. Which critical thinking action will the nurse perform to make this determination? (Select all that apply) 1. Recognize a change in breathing pattern. 2. Analyze color and consistency of sputum 3. Compare vital signs to previous measurements 4. Question the dose of prescribed pain meds 5. Recall interventions used for similar problems Ans: 1, 2, 3 133. A client who smokes cigarettes tells the nurse about planning to use hypnosis for smoking cessation. Which response by the nurse is best? 1 “Hypnosis doesn’t work.” 2 “Most people who use hypnosis for smoking cessation find they smoke more afterward.” 3 “Your chances of success are improved if hypnosis is used in addition to another approach.” 4 “Even though hypnosis is the best approach, you might want to add yoga or massage therapy.” Ans: 3 134. The nurse receives a prescription to start tube feedings on a client with a newly inserted gastrostomy tube whose placement was confirmed with an X-ray. Which action will the nurse take first before starting the feeding? 1 Ask if the client feels hungry. 2 Check the gastric residual volume. 3 Raise head of the bed at least 90 degrees. 4 Change the dressing around the gastrostomy tube. Ans: 2 135. The nurse provides care for a preschool-age client diagnosed with obstructive sleep apnea (OSA) from enlarged adenoids. Which intervention will most likely be used to treat OSA in this client? 1 Weight loss. 2 Continuous Positive Airway Pressure (CPAP). 3 Adenoidectomy. 4 Dental appliance. Ans: 3 136. A child is admitted for suspected meningococcal meningitis. Which action will the nurse take first when providing care? 1 Maintain optimal hydration. 2 Initiate antibiotic therapy. 3 Implement droplet isolation precautions. 4 Begin contact isolation precautions. Ans: 3 137. The nurse teaches the client with type 1 diabetes how to administer insulin. The nurse evaluates that the client has successfully learned when the client makes which statement? 1 “I will use a calibrated insulin syringe for my injection.” 2 “I will use my upper thigh for my insulin injections.” 3 “I will check my blood sugar just after insulin injections.” 4 “I will apply pressure to the site after my injection.” Ans: 1 138. The nurse assesses a newborn whose mother takes insulin to control diabetes mellitus. Which finding indicates to the nurse that the newborn is hypoglycemic? 1 Tremors. 2 Cyanosis. 3 Bradycardia. 4 Sucking while asleep. Ans: 1 139. An older client with extensive wound care requires comprehensive care after discharge. Which facility is most appropriate for the nurse to discuss with the client? 1 Assisted living. 2 Hospice care. 3 Respite care. 4 Skilled nursing. Ans: 4 140. The nurse prepares to administer a prescribed intramuscular (IM) immunization to an infant. Which site does the nurse use to administer the medication? 1 Deltoid. 2 Ventrogluteal. 3 Dorsogluteal. 4 Vastus lateralis. Ans: 4 141. The nurse provides care for a client recovering from surgery. Which action will the nurse perform that demonstrates beneficence when caring for this client? 1 Coaching the client to breathe deeply and cough every hour. 2 Providing pain medication one hour after requested. 3 Applying a wrist restraint to protect an infusion site. 4 Instructing the client on care required at home once discharged. Ans: 1 142. The nurse provides care for a client who had a percutaneous coronary intervention (PCI) with an angiogram 1 hour ago. Which nursing action is priority? 1 Encourage the client to increase fluid intake. 2 Monitor potassium and magnesium levels. 3 Assist the client with toileting needs. 4 Monitor the access site for signs of bleeding. Ans: 4 143. The nurse inserts a nasogastric (NG) tube into a client. Which method accurately verifies initial NG tube placement? 1 Reviewing the X-ray film of the chest/abdomen. 2 Inserting air into the tube while auscultating the abdomen. 3 Measuring pH from the gastrointestinal aspirate. 4 Visualizing the aspirate in the NG tube. Ans: 1 144. The nurse notes that a client has a new onset third degree heart block. The client wants to walk to the bathroom. Which goal is most appropriate for this client? 1 Transfer the client for a cardiac catheterization. 2 Prevent falls or a syncopal episode. 3 Prepare for a temporary pacemaker insertion. 4 Obtain an prescription for an indwelling catheter. Ans: 2 145. The nurse provides care for a newborn client who is 30 minutes old. Which data indicates the need for the nurse to provide follow-up for the newborn? 1 The newborn is exhibiting nasal flaring when supine. 2 The newborn is an abdominal breather. 3 The newborn's respiratory rate is 48 breaths/min. 4 The newborn is experiencing short periods of apnea that last 8 to 10 seconds. Ans: 1 146. The nurse supervises a female nursing student assessing a male client of Arab descent who is experiencing severe headaches. Which student action causes the nurse to immediately intervene? 1 Calls for a male nurse to bring a hospital gown to the room. 2 Sits down at the bedside and closes the privacy curtain. 3 Asks when the headaches started. 4 Explains the 0 to 10 intensity pain scale. Ans: 2 147. The nurse provides care for a client who reports nausea and vomiting following chemotherapy. The client asks the nurse if there is a non-pharmacological supplement to take to relieve these side effects. Which supplement does the nurse recommend? 1 Garlic. 2 Black cohosh. 3 Ginger root. 4 Ginkgo biloba. Ans: 3 148. The nurse is providing care for several clients. Which task will the nurse appropriately delegate to nursing assistive personnel (NAP)? 1 Discontinue an intravenous line. 2 Remove a surgical dressing. 3 Assess vital signs. 4 Obtain a stool sample. Ans: 4 149. A client's vital signs pre-blood transfusion were: temperature 98.40 F (36.80 C); pulse 68 beats per minute; respiratory rate 16 breaths per minute; and blood pressure 118/74 mm Hg. Thirty minutes later, the nurse documents the client’s temperature is now 98.90 F (37.20 C); pulse 72 beats per minute; respiratory rate 18 breaths per minute; and blood pressure 126/68 mm Hg. Which action will the nurse take next? 1 Continue to monitor the client. 2 Slow the transfusion down. 3 Stop the transfusion. 4 Notify the health care provider. Ans: 1 150. The nurse provides care for an adolescent client admitted to the hospital with self-induced severe malnutrition. Which intervention does the nurse implement first? 1 Arrange individual counseling for the client. 2 Administer an oral antidepressant. 3 Administer total parenteral nutrition. 4 Refer parents to support services. Ans: 3 [Show More]

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