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NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE,100% CORRECT

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NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 1) The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the tea... ching session, the client continuously turns away from the nurse. The nurse should implement which best action? ✓ Answers-Continue with the instructions, verifying client understanding. 1) A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5) ✓ Answers-Ensures that a close relative stays with the client ✓ Makes a referral for a Catholic priest to visit the client ✓ Offers to provide a means for praying the rosary if the client wishes. 2) Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5) ✓ Latino American Man ✓ Native American man ✓ Hispanic American man ✓ African American woman 3) The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? ✓ I cannot have any food containing or Prepared with blood." 4) The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? ✓ Answers-Reflecting a cultural value 5) When communicating with a client who speaks a different language, which best practice should the nurse implement? ✓ Arrange for an interpreter to translate. 6) The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response? ✓ Answers-"A person who moves from China to the United States (U.S.) and learns about and adapts ato the culture in the U.S." 7) An Asin American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? ✓ Foods considered to be yin 8) Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? ✓ Sweet and sour chicken with rice and vegetables, mixed fruit, juice. 9) Which is the best nursing intervention regarding complementary and alternative medicine? ✓ Educating the client about therapies that he or she is using or is interested in using 10) An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? ✓ Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 11) The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? ✓ "Magnetic therapy and massage therapy are a focus of CAM." 12) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? ✓ The client was found lying on the floor. 13) A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? ✓ Transport the victim to the operating room for surgery. 14) The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? ✓ Reassess the client. 15) The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? ✓ Clarify with the team leader to make a safe ICU client assignment. 16) The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? ✓ Call the nursing supervisor. 17) A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? ✓ "I will call the nursing supervisor to seek assistance regarding your request." 19) The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. ✓ Document the correct information and end with the nurse's signature and title. ✓ Draw 1 line through the error, initialing and dating it. 20) Which identifies accurate nursing documentation notations? Select all that apply. ✓ The client slept through the night. ✓ Abdominal wound dressing is dry and intact without drainage. ✓ The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 21) A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? ✓ Observing care provided to the client without the client's permission 22) Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? ✓ Slander 23) An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? ✓ As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." 24) The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? ✓ Contact the nursing supervisor. 25) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? ✓ Call the nursing supervisor and report the incident. 26) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? ✓ A client with asthma who requested a breathing treatment during the previous shift 27) The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? ✓ A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 28) A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? ✓ An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients. 29) The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? ✓ A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C) 30) The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? ✓ Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 31) The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? ✓ Confront the UAP to encourage verbalization of feelings regarding the change. 32) The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? ✓ A client who requires urine specimen collections 33) The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. ✓ Move beds away from windows. ✓ Close window shades and curtains. ✓ Place blankets over clients who are confined to bed. 34) The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? ✓ A client requiring abdominal wound irrigations and dressing changes every 3 hours 35) The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. ✓ The acuity level of the clients ✓ Client needs and workers' needs and abilities 36) The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? ✓ An increase in blood pressure and increased respirations 37) The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? ✓ Requires nasogastric suction 38) The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. ✓ U waves ✓ Inverted T waves ✓ Depressed ST segment 39) Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. ✓ Obtain an intravenous (IV) infusion pump. ✓ Monitor urine output during administration. ✓ Monitor the IV site for signs of infiltration or phlebitis. ✓ Ensure that the medication is diluted in the appropriate volume of fluid. ✓ Ensure that the bag is labeled so that it reads the volume of potassium in the solution. 40) The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. ✓ Raisins ✓ Potatoes ✓ Cantaloupe ✓ Strawberries 41) The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. ✓ Peas ✓ Nuts ✓ Cauliflower 42) The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? ✓ Twitching 43) The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. ✓ Prolonged QT interval ✓ Prolonged ST segment 44) The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. ✓ Tall peaked T waves ✓ Widened QRS complexes 45) Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? ✓ The client who is taking diuretics 46) The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? ✓ Hyperactive bowel sounds 47) The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? ✓ Malnutrition 48) The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? ✓ Integumentary output 49) The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? ✓ A client with an ileostomy 50) The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? ✓ Weight loss and poor skin turgor 51) On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? ✓ The client with kidney disease and a 12-year history of diabetes mellitus 52) Which client is at risk for the development of a potassium level of 5.5mEq/L (5.5 mmol/L)? ✓ The client who has sustained a traumatic burn 53) The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO – of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? ✓ Respiratory alkalosis, compensated 54) The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? ✓ Metabolic alkalosis 55) A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? ✓ An increased pH and an increased HCO3– 56) The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO – = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? ✓ The client is probably hyperventilating. 57) The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. ✓ Respirations that are increased in rate ✓ Respirations that are abnormally deep 58) A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO – is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? ✓ Respiratory acidosis without compensation 59) The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. ✓ Nausea ✓ Confusion ✓ Tachycardia ✓ Lightheadedness 60) The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? ✓ pH 7.25, Paco2 50 mm Hg (50 mm Hg) 61) The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? ✓ Potassium level of 3.0 mEq/L (3.0 mmol/L) 62) The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? ✓ Respiratory acidosis from inadequate ventilation 63) A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? ✓ Holding the next dose of warfarin 64) A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? ✓ "I will be sure to cue in to any indicators that the client may be exaggerating their pain." 65) A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? ✓ 15 mg/dL (5.25 mmol/L) 66) The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? ✓ Taking an oral temperature for a client with a cough and nasal congestion 67) A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? 68) A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? ✓ Leaving the rate of the heparin infusion as is 69) A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? ✓ 3.2 mEq/L (3.2 mmol/L) 70) Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. ✓ Platelets 35,000 mm3 (35 × 109/L) ✓ Sodium 150 mEq/L (150 mmol/L) ✓ Segmented neutrophils 40% (0.40) ✓ White blood cells, 3000 mm3 (3.0 × 109/L) 71) The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply. ✓ Warfarin ✓ Glimepiride ✓ Amlodipine 72) A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? ✓ Preventing and recognizing hyperglycemia 73) The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? ✓ 2000 mm3 (2.0 × 109/L) 74) A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? ✓ Draw a sample for prothrombin time (PT) and international normalized ratio (INR). 75) The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? ✓ Attempt to arouse the client. 76) An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? ✓ Iron deficiency anemia 77) A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results? ✓ Place the normal report in the client's medical record. 78) The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? ✓ Oranges and dark green leafy vegetables 79) The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. ✓ Margarine ✓ Cream cheese ✓ Luncheon meats 80) The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? ✓ Cream of wheat, blueberries, coffee 81) The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? ✓ Vitamin B12 82) A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? ✓ Summer squash 83) A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. ✓ Broth ✓ Coffee ✓ Gelatin 84) The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? ✓ Smoked sausage 85) A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? ✓ Custard 86) A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? ✓ Oranges 87) The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? ✓ Legumes 88) A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? ✓ Decrease PN rate to 50 mL/hour. 89) The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? ✓ Take a deep breath, hold it, and bear down. 90) A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? ✓ On the left side, with the head lower than the feet 91) Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? ✓ Determine whether the client has an allergy to eggs. 92) The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? ✓ Weakness, thirst, and increased urine output 93) The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? ✓ Client's temperature 94) The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? ✓ Obtain a different bottle of solution. 95) A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? ✓ Prepare to send them to the laboratory for culture. 96) A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy? ✓ Temperature and weight 97) The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply. ✓ A client with extensive burns ✓ A client with cancer who is septic ✓ A client with severe exacerbation of Crohn's disease ✓ A client with persistent nausea and vomiting from chemotherapy 98) The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution? ✓ Electronic infusion pump 99) The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? ✓ 10% dextrose in water 100) The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? ✓ Ensure that the fat emulsion infusion rate is infusing at the prescribed rate 101) A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? ✓ Crackles on auscultation of the lungs 102) The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? ✓ Secure all connections in the PN system. 103) A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? ✓ Hypervolemia 104) A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? ✓ Slow the IV infusion. 105) The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first? ✓ Check compatibility of the medication and IV fluids. 106) The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank. ✓ 375ml 107) The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. ✓ Pallor and coolness ✓ Numbness and pain ✓ Edema and blanched skin 108) The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? ✓ Blood return shows in the backflash chamber of the catheter. 109) The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? ✓ Remove the IV site and restart at another site. 110) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? ✓ Obtain new IV tubing 111) A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? ✓ Sterile 2 × 2 gauze 112) A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. ✓ Remove the IV catheter at that site. ✓ Apply warm moist packs to the site. ✓ Notify the health care provider (HCP). ✓ Document the occurrence, actions taken, and the client's response. 113) A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client? ✓ 5% dextrose in lactated Ringer's solution 114) he nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? ✓ "I need to restrict my activity while this catheter is in place." 115) A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? ✓ Chest radiology results 116) Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data? ✓ Crackles in the lungs 117) Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6°F (38.1°C) orally. Which action should the nurse take? ✓ Delay hanging the blood and notify the health care provider (HCP). 118) he nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? ✓ "Have you ever had a transfusion before?" 119) A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? ✓ Septicemia 120) The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? ✓ Run normal saline at a keep- vein-open rate. 121) The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? Click on the image to indicate your answer. ✓ Correct Answer Indication: 122) A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? ✓ Decreased oozing of blood from puncture sites and gums 123) A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? ✓ Decreased oozing of blood from puncture sites and gums 124) The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? ✓ Vital signs 125) The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? ✓ Check to be sure that consent for the transfusion has been signed. 126) Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? ✓ Place the client in high Fowler's position. 127) The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? ✓ White blood cell count 128) A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe? ✓ Fresh-frozen plasma 129) The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. ✓ Checks the expiration date ✓ Hangs the blood within the specified time frame per agency policy 130) A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. ✓ Ask a family member to donate blood ahead of time. ✓ Give an autologous blood donation before the surgery. 131) A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? ✓ Blood-warming device 132) A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? ✓ 0.9% sodium chloride 133) The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2°F (36.2°C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? ✓ Compare current data to baseline data. 134) A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? ✓ Page an interpreter from the hospital's interpreter services. 135) The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? ✓ A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 136) The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? ✓ Rhythmic respirations with periods of apnea 137) A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? ✓ A physical obstruction to the transmission of sound waves 138) While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? ✓ A blowing or swooshing noise 139) The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? ✓ Test the 6 cardinal positions of gaze. 140) The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? ✓ After a shower or bath 141) The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? ✓ The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 142) A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? ✓ Wheezes 143) The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. ✓ Auscultating lung sounds ✓ Obtaining the client's temperature ✓ Obtaining information about the client's respirations 144) The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? ✓ Contact the electrical maintenance department for assistance. 145) The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? ✓ Safely securing the safety device straps to the side rails 146) The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. ✓ Inhalation of bacterial spores ✓ Through a cut or abrasion in the skin ✓ Ingestion of contaminated undercooked meat 147) The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? ✓ Every 30 minutes 148) The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? ✓ Placing the client in a semiprivate room at the end of the hallway 149) Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? ✓ Gloves, gown, goggles, and a mask or face shield 150) The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? ✓ Activate the fire alarm. 151) A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? ✓ Call the Poison Control Center. 152) The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? ✓ Activate the emergency response plan. 153) The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? ✓ Private room or cohort client 154) The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? ✓ Isolate the client in a private room. 155) A health care provider's prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ 21 drops per minute 156) A health care provider's prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place. ✓ 1.3 mL 157) A health care provider's prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank. ✓ 15 mL 158) A health care provider's prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters of the medication to administer the correct dose? Fill in the blank. ✓ 2 mL 159) A health care provider's prescription reads phenytoin g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank. ✓ 2 capsule(s) 160) A health care provider prescribes 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ 31 drops per minute 161) A health care provider prescribes heparin sodium, 1300 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number. ✓ 16 mL per hour 162) A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client? Fill in the blank. ✓ 125 mL per hour 163) Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ 33 drops per minute 164) A health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank. ✓ 1.5 tablet(s) 165) Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. ✓ 25 drops per minute 166) A health care provider prescribes 1000 mL D5W to infuse at a rate of 125 mL/hour. The nurse determines that it will take how many hours for 1 L to infuse? Fill in the blank. ✓ 8 hour(s) 167) A health care provider prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ 10 gtt/min 168) A health care provider's prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters to administer the correct dose? Fill in the blank. ✓ 0.8 mL 169) A health care provider prescribes regular insulin, 8 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour? Fill in the blank. ✓ 0.8 mL/hour 170) The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? ✓ Urinary output of 20 mL/hour 171) The nurse is teaching a client about coughing and deep- breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? ✓ "Use of an incentive spirometer will help prevent pneumonia." 172) The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? ✓ Have the client void immediately before going into surgery. 173) A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? ✓ Obtain a telephone consent from a family member, following agency policy. 174) A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse ✓ "Can you share with me what you've been told about your surgery?" 175) The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? ✓ The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. 176) The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? ✓ "I need to continue to take the aspirin until the day of surgery." 177) The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? ✓ Serous drainage 178) The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? ✓ Increasing restlessness 179) A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. ✓ Contact the surgeon. ✓ Instruct the client to remain quiet. ✓ Prepare the client for wound closure. ✓ Document the findings and actions taken. 180) A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? ✓ Hemoglobin, 8.0 g/dL (80 mmol/L) 181) The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? ✓ Assess the patency of the airway. 182) The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? ✓ Prednisone 183) A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? ✓ Lying in bed on the unaffected side 184) The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Click on the image to indicate your answer. ✓ Correct Answer Indication: ✓ 185) The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? ✓ Bed rest with elevation of the affected extremity 186) The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? ✓ On the nonoperative side with the legs abducted 187) The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? ✓ "I should sleep on my left side." 188) The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? ✓ Left Sims' position 189) A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? ✓ Supine, with the residual limb supported with pillows 190) The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? ✓ Elevate and immobilize the grafted extremity. 191) The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure? ✓ Bed rest with head elevation no greater than 30 degrees 192) The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? ✓ High Fowler's 193) The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. ✓ Check the residual volume. ✓ Aspirate the stomach contents. ✓ Turn off the suction to the nasogastric tube. ✓ Test the stomach contents for a pH indicating acidity. 194) The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? ✓ Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. 195) The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time? ✓ Call the health care provider to request a prescription for a chest radiograph. 196) The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? ✓ Place the tube in a bottle of sterile water. 197) The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? ✓ Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. 198) The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. ✓ Drainage system maintained below the client's chest ✓ 50 mL of drainage in the drainage collection chamber ✓ Occlusive dressing in place over the chest tube insertion site ✓ Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation 199) The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? ✓ Perform the Valsalva maneuver. 200) While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? ✓ Grasp the retention sutures to spread the opening. 201) The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? ✓ Stridor 202) The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? ✓ Hold the feeding and reinstill the residual amount. 203) The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? ✓ Check for an air leak, because the bubbling should be intermittent. 204) The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? ✓ Pull back on the tube and wait until the respiratory distress subsides. 205) The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? ✓ Punishment and reward 206) The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? ✓ Allow the newborn infant to signal a need. 207) The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? ✓ Report the observation to the health care provider. 208) A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to this stage of development? ✓ This stage is associated with toilet training. 209) The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? ✓ The child has the ability to think abstractly. 210) The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? ✓ "At this age, the child is developing his own personality." 211) The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply. ✓ Moral development progresses in relationship to cognitive development. ✓ A person's ability to make moral judgments develops over a period of time. ✓ The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. ✓ In stage 2 (instrumental- relativist orientation), the child conforms to rules to obtain rewards or have favors returned. 212) A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply. ✓ Set limits on the child's behavior. ✓ Provide a simple explanation of why the behavior is unacceptable. 213) A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? ✓ Encourage the child's parents to stay with the child. 214) A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? ✓ Allow the client to interact with others in his or her (adolescent) same age group. 215) Which car safety device should be used for a child who is 8 years old and 4 feet tall? ✓ Booster seat 216) The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate? ✓ Document the findings. 217) The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? ✓ Document the finding. 218) The nurse is evaluating the developmental level of a 2- year-old. Which does the nurse expect to observe in this child? ✓ Uses a cup to drink 219) A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? ✓ "We will be sure not to leave hot liquids unattended." 220) A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? ✓ Inform the child of bedtime a few minutes before it is time for bed. 221) The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? ✓ Allow the bottle if it contains water. 222) The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? ✓ Crayons and a coloring book 223) The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year- old is which? ✓ A wagon 224) Which interventions are appropriate for the care of an infant? Select all that apply. ✓ Provide swaddling. ✓ Hang mobiles with black and white contrast designs. ✓ Caress the infant while bathing or during diaper changes. 225) The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. ✓ Encourage expression of feelings, concerns, and fears. ✓ Touch and hold the client's or family member's hand if appropriate. ✓ Be honest and let the client and family know they will not be abandoned by the nurse. 226) The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? ✓ Increased risk for digoxin toxicity 227) The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? ✓ Allowing the client to choose social activities 228) The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. ✓ Looking at old snapshots of family ✓ Participating in a senior citizens program ✓ Visiting the spouse's grave once a month ✓ Decorating a wall with the spouse's pictures and awards received 229) The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. What should the nurse tell the UAP about older clients with hearing loss? ✓ They respond to low-pitched tones. 230) The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse? ✓ A woman who has advanced Parkinson's disease 231) The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? ✓ "I drink hot chocolate before bedtime." 232) The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? ✓ Suggest appropriate resources to the client and daughter-in- law, such as respite care and a senior citizens center. 233) The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? ✓ Crusting 234) The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? ✓ Determine whether there are medication duplications. 235) The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply. ✓ Decline in visual acuity ✓ Increased susceptibility to urinary tract infections ✓ Increased incidence of awakening after sleep onset 236) The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. ✓ "The ductus arteriosus allows blood to bypass the fetal lungs." ✓ "One vein carries oxygenated blood from the placenta to the fetus." ✓ "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 237) The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? ✓ "It connects the umbilical vein to the inferior vena cava." 238) A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? ✓ The appearance of the fetal external genitalia 239) The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? ✓ Notify the health care provider (HCP). 240) The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? ✓ "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 241) The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. ✓ Allows for fetal movement ✓ Surrounds, cushions, and protects the fetus ✓ Maintains the body temperature of the fetus ✓ Can be used to measure fetal kidney function 242) A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? ✓ "Do you plan to have any other children?" 243) The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? ✓ "Your type of pelvis is the most favorable for labor and birth." 244) Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. ✓ It is the way the baby gets food and oxygen. ✓ It provides an exchange of nutrients and waste products between the mother and developing fetus. 245) A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? ✓ "Please share with me more about your concerns." 246) The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? ✓ An informed consent needs to be signed before the procedure. 247) A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? ✓ "The vaginal discharge may be bothersome, but is a normal occurrence." 248) A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? ✓ A normal test result 249) A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. ✓ Pregnancy needs to be avoided for 1 to 3 months. ✓ The vaccine is administered by the subcutaneous route. ✓ Exposure to immunosuppressed individuals needs to be avoided. ✓ A hypersensitivity reaction can occur if the client has an allergy to eggs. 250) The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? ✓ "I need to lie flat on my back to perform the procedure." 251) The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? ✓ The client is measuring normal for gestational age. 252) The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. ✓ Ballottement ✓ Chadwick's sign ✓ Uterine enlargement ✓ Positive pregnancy test 253) A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? ✓ Inform the client that these contractions are common and may occur throughout the pregnancy. 254) A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? ✓ July 26, 2019 255) The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? ✓ G = 2, T = 1, P = 0, A = 0, L = 1 256) The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? ✓ "You will need to bottle-feed your newborn." 257) The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? ✓ The client complains of a headache and blurred vision. 258) A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? ✓ "What can I do for you?" 259) The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? ✓ "I should avoid exercise because of the negative effects on insulin production." 260) The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? ✓ Evidence of bleeding, such as in the gums, petechiae, and purpura 261) The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. ✓ A gravida II who has just been diagnosed with dead fetus syndrome ✓ A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia 262) The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. ✓ Proteinuria ✓ Hypertension 263) The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? ✓ "I will need to increase my insulin dosage during the first 3 months of pregnancy." 264) A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? ✓ Isoniazid plus rifampin will be required for 9 months. 265) The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? ✓ "I should drink adequate fluids and increase my intake of high-fiber foods." 266) The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. ✓ The client has a history of intravenous drug use. ✓ The client has a history of sexually transmitted infections. 267) The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? ✓ "We want to attend a support group." 268) The nurse evaluates the ability of a hepatitis B– positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? ✓ The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. 269) A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? ✓ "I will maintain strict bed rest throughout the remainder of the pregnancy." 270) The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. ✓ Routine administration of subcutaneous heparin may be prescribed. ✓ An overbed lift may be necessary if the client requires a cesarean section. ✓ Thromboembolism stockings or sequential compression devices may be prescribed. 271) The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. ✓ The cervix is dilated completely. ✓ The spontaneous urge to push is initiated from perineal pressure. 272) The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? ✓ Administer oxygen via face mask. 273) The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? ✓ Fetal heart rate of 180 beats/minute 274) The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the –1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer. ✓ Indication: ✓ 275) A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a –2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. ✓ Increased efficiency of contractions ✓ The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord 276) The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? ✓ Variable decelerations 277) A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? ✓ Supine position with a wedge under the right hip 278) The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? ✓ Notify the health care provider (HCP). 279) The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? ✓ Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. 280) The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? ✓ Assess the baseline fetal heart rate. 281) The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? ✓ "My contractions will increase in duration and intensity." 282) Which assessment following an amniotomy should be conducted first? ✓ Fetal heart rate pattern 283) The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? ✓ Rest between contractions 284) The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? ✓ Discontinue the infusion of oxytocin. 285) The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? ✓ Uterine tenderness 286) The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? ✓ Obtain equipment for a manual pelvic examination. 287) An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? ✓ Delivery of the fetus 288) The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? ✓ The client has a history of cardiac disease. 289) The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. ✓ Age 54 ✓ Body mass index of 28 ✓ Previous difficulty with fertility 290) The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? ✓ Persistent nonreassuring fetal heart rate 291) The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? ✓ Provide pain relief measures. 292) The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? ✓ Perform a vaginal examination every shift. 293) The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? ✓ Monitoring the fetal heart rate 294) Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? ✓ Administer oxygen, 8 to 10 L/minute, via face mask. 295) The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? ✓ Hemorrhage 296) The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. ✓ Bright red vaginal bleeding ✓ Soft, relaxed, nontender uterus ✓ Fundal height may be greater than expected for gestational age 297) The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? ✓ Place the client in Trendelenburg's position. 298) The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action? ✓ Increase hydration by encouraging oral fluids. 299) The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? ✓ Instruct the client to request help when getting out of bed. 300) The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? ✓ 3 days postpartum 301) The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? ✓ Client pain level 302) The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. ✓ "I should wear a bra that provides support." ✓ "Drinking alcohol can affect my milk supply." ✓ "The use of caffeine can decrease my milk supply." ✓ "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." 303) The nurse is teaching a postpartum client about breast- feeding. Which instruction should the nurse include? ✓ The diet should include additional fluids. 304) The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? ✓ Massage the fundus until it is firm. 305) The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? ✓ The client with lochia that is red and has a foul-smelling odor 306) When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? ✓ Notify the health care provider (HCP). 307) The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? ✓ Contact the health care provider (HCP) and inform the HCP of this finding. 308) The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? ✓ "I will begin abdominal exercises immediately." 309) After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? ✓ Support the mother in her reaction to the newborn infant. 310) The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? ✓ An increase in the pulse rate from 88 to 102 beats/minute 311) The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. ✓ Wear a supportive bra. ✓ Rest during the acute phase. ✓ Maintain a fluid intake of at least 3000 mL/day. ✓ Continue to breast-feed if the breasts are not too sore. 312) The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast- feeding her newborn. Which client statement would indicate a need for further instruction? ✓ "I should wash my nipples daily with soap and water." 313) The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? ✓ Enlarged, hardened veins 314) A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? ✓ Administer oxygen, 8 to 10 L/minute, by face mask. 315) The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? ✓ Notify the health care provider (HCP). 316) The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? ✓ A multiparous client who delivered a large baby after oxytocin induction 317) A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? ✓ Encouraging fluid intake 318) The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? ✓ Changes in vital signs 319) The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? ✓ Prepare an ice pack for application to the area. 320) On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? ✓ Massage the fundus until it is firm. 321) The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? ✓ Drying the infant with a warm blanket 322) The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? ✓ Bring the infant to the clinic. 323) The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? ✓ Connect the resuscitation bag to the oxygen outlet. 324) The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? ✓ Document the findings. 325) The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. ✓ Cyanosis ✓ Tachypnea ✓ Retractions ✓ Audible grunts 326) The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? ✓ Continue to breast-feed every 2 to 4 hours. 327) The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. ✓ Irritability ✓ Constant crying ✓ Difficult to comfort 328) The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? ✓ Abnormal palmar creases 329) The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? ✓ Monitor the newborn's response to feedings and weight gain pattern. 330) The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? ✓ Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection. 331) The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. ✓ Monitor skin temperature closely. ✓ Reposition the newborn every 2 hours. ✓ Cover the newborn's eyes with eye shields or patches. 332) The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? ✓ Maintaining standard precautions at all times while caring for the newborn 333) The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? ✓ Maintaining safety because of low blood glucose levels 334) Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? ✓ "I will ask the nurse to attend to my infant if I am napping and my husband is not here." 335) The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? ✓ "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." 336) The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. ✓ Uterine hyperstimulation ✓ Late decelerations of the fetal heart rate 337) A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. ✓ Respirations of 10 breaths/minute ✓ Urine output of 20 mL in an hour 338) The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication? ✓ "I will flush the eyes after instilling the ointment." 339) A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? ✓ Betamethasone 340) Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? ✓ Blood pressure 341) The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route? ✓ Intratracheal 342) An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur? ✓ Naloxone 343) Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? ✓ Being affected by Rh incompatibility 344) Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history? ✓ Peripheral vascular disease 345) The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. ✓ Flushing ✓ Depressed respirations ✓ Extreme muscle weakness 346) The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? ✓ Adequacy of capillary filling 347) The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? ✓ Fine grayish red lines 348) Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? ✓ Apply the lotion to cool, dry skin at least 30 minutes after bathing. 349) The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? ✓ "Lesions most often are located on the arms and chest." 350) The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? ✓ The child is 18 months old. 351) A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? ✓ Apply a thin layer of cream and rub it into the area thoroughly. 352) The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check? ✓ White sacs attached to the hair shafts in the occipital area 353) The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. ✓ A delay in growth may occur after a burn injury. ✓ An immature immune system presents an increased risk of infection for infants and young children. ✓ Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults. 354) The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? ✓ Partial thromboplastin time 355) The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child? ✓ Swimming 356) The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these? ✓ A child of Mediterranean descent 357) A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed? ✓ Deferoxamine 358) The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? ✓ Fluid overload 359) A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? ✓ Intravenous infusion of factor VIII 360) The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents? ✓ Administer the iron through a straw. 361) Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? ✓ Red blood cells that are microcytic and hypochromic 362) The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. ✓ Restrict fluid intake 363) Give meperidine, 25 mg intravenously, every 4 hours for pain. 364) The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. ✓ Easy bruising occurs. ✓ Gum bleeding occurs. ✓ It is a hereditary bleeding disorder. ✓ Treatment and care are similar to that for hemophilia ✓ The disorder causes platelets to adhere to damaged endothelium. 365) The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately? ✓ Notify the health care provider (HCP). 366) A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? ✓ Notify the health care provider (HCP). 367) The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? ✓ Palpating the abdomen for a mass 368) The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? ✓ "The child does not experience pain at the primary tumor site." 369) The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? ✓ Initiate bleeding precautions. 370) The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? ✓ Vomiting 371) A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis? ✓ Bone marrow biopsy showing blast cells 372) A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? ✓ "The flowers from your garden are beautiful, but should not be placed in the child's room at this time." 373) A diagnosis of Hodgkin's disease is suspected in a 12- year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? ✓ The presence of Reed-Sternberg cells in the lymph nodes 374) Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. ✓ Reduce exposure to environmental organisms. ✓ Use strict aseptic technique for all procedures. ✓ Ensure that anyone entering the child's room wears a mask. 375) The nurse is performing an assessment on a 10-year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply. ✓ Abdominal pain ✓ Painless, firm, and movable adenopathy in the cervical area 376) A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? ✓ Eat a small box of raisins or drink a cup of orange juice before soccer practice. 377) The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? ✓ Encourage the child to drink liquids. 378) A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? ✓ Checks the amount of urine output 379) An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? ✓ Fruity breath odor and decreasing level of consciousness 380) A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation? ✓ It is negative. 381) A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? ✓ Normal saline infusion 382) The nurse has just administered ibuprofen to a child with a temperature of 102°F (38.8°C). The nurse should also take which action? ✓ Remove excess clothing and blankets from the child. 383) A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? ✓ Capillary refill is less than 2 seconds. 384) The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. ✓ Prepare to administer glucagon subcutaneously if unconsciousness occurs. ✓ Give the child a teaspoon of honey. 385) The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? ✓ Foul-smelling ribbon-like stools 386) An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? ✓ Left lateral position 387) The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? ✓ Choking with feedings 388) The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? ✓ Thicken the feedings by adding rice cereal to the formula. 389) A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? ✓ Metabolic alkalosis 390) The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? ✓ Failure to pass meconium stool in the first 24 hours after birth 391) The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? ✓ Projectile vomiting 392) The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? ✓ Rice 393) The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? ✓ Bright red blood and mucus in the stools 394) Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. ✓ Providing a low-fat, well- balanced diet ✓ Teaching the child effective hand-washing techniques ✓ Instructing the parents to avoid administering medications unless prescribed 395) After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? ✓ Turn the child to the side. 396) The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? ✓ Possible sexual abuse 397) The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? ✓ "It is okay to share towels and washcloths." 398) The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review? ✓ Prothrombin time 399) The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? ✓ Side-lying 400) After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question? ✓ Suction every 2 hours. 401) The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? ✓ Frequent swallowing 402) Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided? ✓ "Administer the antibiotics until they are gone." 403) The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? ✓ The child consistently tilts the head to see. 404) A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. ✓ Provide a soft diet ✓ Administer ibuprofen for fever every 4 hours as prescribed and as needed. ✓ Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy. 405) A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? ✓ Decreased wheezing 406) The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? ✓ Encourage the child to lie on the right side 407) A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? ✓ Back rather than on the stomach 408) The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? ✓ "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." 409) The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? ✓ The child is leaning forward, with the chin thrust out. 410) A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? ✓ Let the mother hold the child and direct the cool mist over the child's face. 411) The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? ✓ Positive 412) The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? ✓ "Antibiotics are not indicated unless a bacterial infection is present 413) The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? ✓ Move the infant to a room with another child with RSV. 414) The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. ✓ Place the infant in a private room. ✓ Ensure that nurses caring for the infant with RSV do not care for other high-risk children. 415) The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? ✓ Tachycardia 416) The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? ✓ Anti–streptolysin O titer 417) On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? ✓ Conjunctival hyperemia 418) The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? ✓ "If my child vomits after medication administration, I will repeat the dose." 419) The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? ✓ Weighing the diapers 420) The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? ✓ Exercise intolerance 421) The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? ✓ "I can apply lotion or powder to the incision if it is itchy." 422) A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? ✓ "Did the child have a sore throat or fever within the last 2 months?" 423) A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? ✓ When drawing blood for electrolyte level testing 424) Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to the figure (circled area) to determine the condition. View Figure ✓ Patent ductus arteriosus 425) The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis? ✓ "I noticed his urine was the color of coca-cola lately." 426) The nurse performing an admission assessment on a 2- year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? ✓ Generalized edema 427) The nurse is planning care for a child with hemolytic- uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? ✓ Restrict fluids as prescribed. 428) A 7-year-old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents? ✓ Primary nocturnal enuresis is usually outgrown without therapeutic intervention. 429) The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction? ✓ "I'll let him decide when to return to his play activities." 430) The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? ✓ "Circumcision has been delayed to save tissue for surgical repair." 431) The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? ✓ Cover the bladder with a nonadhering plastic wrap. 432) Which question should the nurse ask the parents of a child suspected of having glomerulonephritis? ✓ "Has the child had a sore throat or a throat infection in the last few weeks?" 433) The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? ✓ Bacteriuria 434) The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. ✓ Pallor ✓ Edema ✓ Anorexia ✓ Proteinuria 435) The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? ✓ A chronic disability characterized by impaired muscle movement and posture 436) The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? ✓ Meningitis 437) A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? ✓ Bradycardia 438) The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should contact the HCP to question which prescription? ✓ Nasotracheal suction as needed 439) The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? ✓ Rigid extension and pronation of the arms and legs 440) A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? ✓ Providing a quiet atmosphere with dimmed lighting 441) The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? ✓ Suctioning equipment and oxygen 442) A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? ✓ Cloudy CSF, elevated protein, and decreased glucose levels 443) The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? ✓ Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. 444) An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? ✓ Reposition the infant frequently. 445) The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. ✓ Time the seizure ✓ Stay with the child. ✓ Move furniture away from the child. 446) A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? ✓ Notify the health care provider (HCP). 447) A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? ✓ Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied. 448) A 4-year-old child sustains a fall at home. After an x- ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? ✓ "I can use lotion or powder around the cast edges to relieve itching." 449) The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of- motion exercises at this time. The nurse should make which response? ✓ "Have the child perform simple isometric exercises during this time." 450) A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? ✓ Notify the health care provider (HCP). 451) The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? ✓ "I should apply lotion under the brace to prevent skin breakdown." 452) The nurse is assisting a health care provider (HCP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess? ✓ Ortolani's maneuver 453) A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? ✓ Limited range of motion in the affected hip 454) Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? ✓ "I need to bring my infant back to the clinic in 1 month for a new cast." 455) The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. ✓ Keep small toys and sharp objects away from the cast. ✓ Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. ✓ Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. 456) An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? ✓ Cough 457) The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? ✓ "I can send my child to day care if he has a fever, as long as it is a low-grade fever." 458) The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? ✓ The inactivated influenza vaccine will be given yearly. 459) A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? ✓ p24 antigen assay 460) The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother? ✓ "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old." 461) A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? ✓ "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." 462) The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should expect which statement that is aligned with the psychosocial expectations of this age? ✓ "I know it hurts to die." 463) The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? ✓ "I will clean up any spills from the diaper with diluted alcohol." 464) Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. ✓ Monitor the child's weight. ✓ Frequent hand washing is important. ✓ The child should avoid exposure to other illnesses. ✓ Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 465) The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? ✓ "We need to maintain droplet precautions and a quiet environment for at least 2 weeks." 466) An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? ✓ Apply a cold pack to the injection site. 467) A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? ✓ A previous dose of hepatitis B vaccine or component 468) A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? ✓ DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV) 469) The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. ✓ The child had a previous anaphylactic reaction to the vaccine. ✓ The child has a disorder that caused a severely deficient immune system. 470) The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? ✓ "I should mix the medication in the baby food and give it when I feed my child." 471) A health care provider's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL." The nurse prepares to draw up how many milliliters to administer 1 dose? ✓ 0.925 mL 472) A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the client at each dose? ✓ 28.8 mcg 473) Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? ✓ 2 tablets 474) Penicillin G procaine, 1,000,000 units IM (intramuscularly), is prescribed for a child with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the child? ✓ 1.7 mL 475) The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? ✓ Vastus lateralis 476) Atropine sulfate, 0.6 mg intramuscularly, is prescribed for a child preoperatively. The nurse has determined that the dose prescribed is safe and prepares to administer how many milliliters to the child? Fill in the blank (refer to figure). View Figure ✓ 1.5 mL 477) The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? ✓ Move the victim to a safe area away from the snake and encourage the victim to rest. 478) A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? ✓ "Take a shower immediately, lathering and rinsing several times." 479) A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? ✓ A skin infection of the dermis and underlying hypodermis 480) The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. ✓ Thinner and decrease in number of reddish papules ✓ Scarce amount of silvery-white scaly patches on the arms 481) The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? ✓ Positive culture results 482) A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. ✓ Lesion is highly metastatic. ✓ Lesion is a nevus that has changes in color. 483) When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. ✓ A pearly papule with a central crater and a waxy border ✓ Location in the bald spot atop the head that is exposed to outdoor sunlight 484) A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? ✓ A white color to the skin, which is insensitive to touch 485) The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? ✓ Partial-thickness skin loss of the dermis 486) An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? ✓ 36% 487) The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? ✓ Return of distal pulses 488) A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? ✓ Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 489) A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. ✓ Assess for airway patency. ✓ Administer oxygen as prescribed. ✓ Elevate extremities if no fractures are present. 490) The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? ✓ Elevated hematocrit levels 491) The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. ✓ The nurse who never had chickenpox ✓ The nurse who never received the varicella-zoster vaccine 492) A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? ✓ 100% oxygen via a tight- fitting, nonrebreather face mask 493) The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial- thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? ✓ Urine output 494) The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? ✓ Wearing gloves and a gown only when giving direct care to the client 495) The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? ✓ Immobilization of the affected leg 496) The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? ✓ Flushing 497) Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? ✓ Tinnitus 498) The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply ✓ Use sunscreen when participating in outdoor activities. ✓ Wear a hat, opaque clothing, and sunglasses when in the sun. ✓ Examine your body monthly for any lesions that may be suspicious. 499) Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? ✓ White blood cell count of 3000 mm3 (3.0 × 109/L) 500) A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? ✓ Hyperventilation 501) Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? ✓ Triglyceride level 502) A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the HCP if the client is also taking which medication? ✓ Vitamin A 503) The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. ✓ Back ✓ Soles of the feet ✓ Palms of the hands 504) The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with use of this medication? ✓ Itching 505) Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? ✓ "The medication is likely to cause stinging every time it is applied." 506) The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? ✓ At least 30 minutes before exposure to the sun 507) The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? ✓ Increased calcium level 508) The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? ✓ Encouraging fluids 509) When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. ✓ Keeping pregnant women out of the client's room ✓ Placing the client in a private room with a private bath ✓ Wearing a lead shield when providing direct client care 510) While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? ✓ Pick up the implant with long- handled forceps and place it in a lead container. 511) The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? ✓ Teach the client and family about the need for hand hygiene. 512) The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? ✓ The client's pain rating 513) The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet? ✓ Bowel sounds 514) A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? ✓ Enlarged lymph nodes 515) During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? ✓ Abdominal distention 516) The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. ✓ Facial edema in the morning ✓ Serum calcium level of 12 mg/dL (3.0 mmol/L) ✓ Numbness and tingling of the lower extremities 517) A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? ✓ The development of a vesicovaginal fistula 518) The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? ✓ That the best time for the examination is after a shower 519) The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply. ✓ Pathological fracture ✓ Urinalysis positive for nitrites ✓ Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) 520) A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? ✓ Continue to monitor the drainage. 521) The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? ✓ Age younger than 50 years 522) The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? ✓ Change the dressing as prescribed. 523) The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? ✓ The passage of flatus 524) The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? ✓ Hematuria 525) The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? ✓ "I empty the urinary collection bag when it is two- thirds full." 526) A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. ✓ Radiation ✓ Chemotherapy ✓ Serum sodium level determination ✓ Medication that is antagonistic to antidiuretic hormone 527) The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? ✓ Periorbital edema 528) The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? ✓ Electrocardiographic changes 529) As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? ✓ "I'm going to take aspirin for my headache as soon as I get home." 530) The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? ✓ 1 week after menstruation begins 531) A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. ✓ Peritonitis ✓ Hemorrhage ✓ Fistula formation ✓ Bowel perforation 532) The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? ✓ Elevating the affected arm on a pillow above heart level 533) Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy? ✓ Measure the client's current weight and height. 534) A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? ✓ Pulmonary function studies 535) A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication? ✓ Uric acid level 536) A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication? ✓ Orthostatic hypotension 537) A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? ✓ "You need to consult with the health care provider (HCP) before receiving immunizations." 538) A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication? ✓ Peripheral neuropathy 539) The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse contacts the health care provider before administering the medication if which disorder is documented in the client's history? ✓ Pancreatitis 540) Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement? ✓ "This medication can be taken to prevent and treat clients with breast cancer." 541) A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? ✓ Calcium level 542) Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the health care provider if which diagnosis is documented in the client's history? ✓ Venous thromboembolism 543) The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. ✓ Stop the infusion. ✓ Notify the health care provider (HCP). ✓ Prepare to apply ice or heat to the site. ✓ Prepare to administer a prescribed antidote into the site. 544) The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? ✓ Increased uric acid level 545) The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action? ✓ Increase fluid intake to 2000 to 3000 mL daily. 546) A client with non–Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication? ✓ Crackles on auscultation of the lungs 547) The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? ✓ A platelet count of 50,000 mm3 (50 × 109/L) 548) A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? ✓ Intravenous infusion of normal saline 549) An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? ✓ It administers a small continuous dose of short- duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. 550) A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. ✓ Comatose state ✓ Deep, rapid breathing ✓ Elevated blood glucose level 551) The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. ✓ Shakiness ✓ Palpitations ✓ Lightheadedness 552) A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? ✓ Convey empathy, trust, and respect toward the client. 553) The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? ✓ "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." 554) A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? ✓ IV fluids containing dextrose 555) The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? ✓ Polyuria 556) The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? ✓ Inadequate fluid volume 557) The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? ✓ "I need to stop my insulin." 558) The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? ✓ Test the drainage for glucose. 559) The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. ✓ Initiate an infusion of 3% NaCl. ✓ Restrict fluids to 800 mL over 24 hours ✓ Administer a vasopressin antagonist as prescribed. 560) A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? ✓ Maintain a patent airway. 561) The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? ✓ Administer short-duration insulin intravenously. 562) A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise ✓ "The best time for me to exercise is after breakfast." 563) The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. ✓ Polyuria ✓ Bone pain 564) The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? ✓ "I should limit my fluids to 1 liter per day." 565) client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. ✓ Hypotension ✓ Hyperkalemia 566) The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. ✓ Tremors ✓ Irritability ✓ Nervousness 567) The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? ✓ A heart rate that is 90 beats/minute and irregular 568) The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. ✓ Leukocytosis ✓ Urinary output of 800 mL/hour ✓ Clear drainage on nasal dripper pad 569) The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? ✓ Temperature 570) The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. ✓ Feeling cold ✓ Loss of body hair ✓ Persistent lethargy ✓ Puffiness of the face 571) A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? ✓ Respiratory distress 572) A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. ✓ Fever ✓ Nausea ✓ Tremors ✓ Confusion 573) The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? ✓ Withdraws the NPH insulin first 574) The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? ✓ Refrigerate the insulin. 575) Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply. ✓ Red meats ✓ Whole-grain cereals ✓ Carbonated beverages 576) The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching? ✓ "I need to constantly watch for signs of low blood sugar." 577) The health care provider (HCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention? ✓ Withhold the medication and call the HCP, questioning the prescription for the client. 578) A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. ✓ Hypoglycemia may be experienced before dinnertime. ✓ The insulin should be administered at room temperature. 579) The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply. ✓ Diarrhea may occur secondary to the metformin ✓ The repaglinide is not taken if a meal is skipped. ✓ The repaglinide is taken 30 minutes before eating. ✓ A simple sugar food item is carried and used to treat mild hypoglycemia episodes. 580) The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary? ✓ "I can take aspirin or my antihistamine if I need it." 581) A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply. ✓ Administer methimazole with food. ✓ Assess the client for unexplained bruising or bleeding. ✓ Instruct the client to report side and adverse effects such as sore throat, fever, or headaches. 582) The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. ✓ Insomnia ✓ Weight loss ✓ Mild heat intolerance 583) The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way? ✓ On an empty stomach 584) The nurse should tell the client, who is taking levothyroxine, to notify the health care provider (HCP) if which problem occurs? ✓ Tremors 585) The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching? ✓ "Take your prescribed pills 1 hour before or 2 hours after the injection." 586) The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. ✓ "I should decrease my oral fluids when I start this medication." ✓ "I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin." 587) A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication? ✓ Early morning 588) The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply. ✓ "I should sit up for at least 30 minutes after taking this medication." ✓ "I should take this medication first thing in the morning on an empty stomach." 589) A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10.2 to 11.4 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? ✓ Prednisone 590) The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? ✓ Notify the health care provider (HCP). 591) A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. ✓ Gray-blue color at the flank ✓ Abdominal guarding and tenderness ✓ Left upper quadrant pain with radiation to the back 592) The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. ✓ Fever ✓ Complaints of indigestion ✓ Pain in the upper right quadrant after a fatty meal 593) A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? ✓ Increase intake of fluids, including juices. 594) A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? ✓ Malaise 595) A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. ✓ Administer stool softeners as prescribed. ✓ Encourage a high-fiber diet to promote bowel movements without straining. ✓ Apply cold packs to the anal- rectal area over the dressing until the packing is removed. 596) The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. ✓ Coffee ✓ Chocolate ✓ Peppermint ✓ Fried chicken 597) A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? ✓ Assessing for the return of the gag reflex 598) The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? ✓ "I'm glad I don't have to lie still for this procedure." 599) The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? ✓ "I ate shellfish about 2 weeks ago at a local restaurant." 600) The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. ✓ Nuts ✓ Liver ✓ Lentils 601) The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? ✓ Document the findings. 602) The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? ✓ A rigid, boardlike abdomen 603) The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? ✓ Irrigating the nasogastric tube 604) The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? ✓ Limit the fluids taken with meals. 605) The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. ✓ Maintain NPO (nothing by mouth) status. ✓ Encourage coughing and deep breathing. ✓ Give hydromorphone intravenously as prescribed for pain. 606) The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? ✓ "I should increase the fiber in my diet." 607) The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? ✓ Ask the client to extend the arms. 608) The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? ✓ Pasta with sauce 609) The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? ✓ Pain relieved by food intake 610) A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? ✓ Lying recumbent following meals 611) The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? ✓ Purple discoloration of the stoma 612) A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? ✓ This is a normal, expected event 613) A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? ✓ Fluid and electrolyte imbalance 614) The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? ✓ "I need to limit my intake of dietary fiber." 615) The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? ✓ Sweating and pallor 616) A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? ✓ Checking the frequency and consistency of bowel movements 617) A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? ✓ An episode of diarrhea 618) A client has an as needed prescription for ondansetron. For which condition(s) should the nurse administer this medication? ✓ Nausea and vomiting 619) A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? ✓ Reduction of steatorrhea 620) An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication? ✓ Confusion 621) A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times? ✓ One hour before meals and at bedtime 622) A client who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted? ✓ Relief of epigastric pain 623) A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? ✓ Heartburn 624) A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? ✓ "The medications will kill the bacteria and stop the acid production." 625) A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition? ✓ Vomiting following cancer chemotherapy 626) The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply. ✓ "I will take the cimetidine with my meals." ✓ I'll know the medication is working if my diarrhea stops." ✓ "Taking the cimetidine with an antacid will increase its effectiveness." 627) The nurse has given instructions to a client who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction? ✓ "This medication should only be taken with water." 628) The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? ✓ Diminished breath sounds 629) The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. ✓ A hyperinflated chest noted on the chest x-ray ✓ Decreased oxygen saturation with mild exercise 630) The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? ✓ Promote carbon dioxide elimination. 631) The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. ✓ Activities should be resumed gradually. ✓ A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. ✓ Respiratory isolation is not necessary because family members already have been exposed. ✓ Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 632) The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? ✓ Bronchospasm 633) The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? ✓ 10 seconds 634) The nurse is suctioning a client via an endotracheal tube.