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AA RN Comprehensive Predictor 2021: Complete and All Final Question on Predictor. With Over 500 Q&A for nursing school personnel and nursing school students Guaranteed upon Download.

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RN Comprehensive Predictor 2021 Form A | AA RN Comprehensive Predictor 2021 : Complete and All Final Question on Predictor. With Over 500 Q&A for nursing school personnel and nursing school students t... o Guarantee success on the AA RN Comprehensive Predictor 2021:Also ATI NCLEX Predictor. With 180 Q&A for nursing school personnel and nursing school students to Guarantee success on the NCLEX. 100% Correct.. 100% Graded A. | 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the catheter insertion. C. Use a mummy restraint to hold the child during the catheter insertion. D. Require the parents to leave the room during the procedure. 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? A. Thrill upon palpation. B. Absence of a bruit. C. Distended blood vessels D. Swishing sound upon auscultation. 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. “I will soak in the tub rather and showering” B. “I will wear loose clothing around my ICD” C. “I will stop using my microwave oven at home because of my ICD” D. “I can hold my cellphone on the same side of my body as the ICD” 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? A. “Describe your feelings to me about being pregnant” B. “You should discuss your feelings about being pregnant with your provider” C. “Have you discussed these feelings with your partner?” D. “When did you start having these feelings?” 5. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client’s diet. C. Provide the client with a cold drink prior to defecation. D. Administer a rectal suppository 30 minutes prior to scheduled defecation times. 6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. 7. a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm 8. a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client’s restraint every 4hr B. Document the client’s condition every 15 min C. Attach the restrain to the bed’s side rails D. Request a PRN restrain prescription for clients who are aggressive 9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care . A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 % D. Random serum glucose 190 mg/dl. 11. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus 12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? A. Share personal opinions to help influence the group’s values B. Measure the accomplishments of the group against a previous group C. Yield in situations of conflicts to maintain group harmony D. Use modeling to help the clients improve their interpersonal skills 13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care? A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next. A. Monitor the client’s IV site for thrombophlebitis. B. Administer flumazenil to the client. C. Evaluate the client for further suicidal behavior. D. Initiate seizure precautions for the client. 16. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? A. Hypotension B. Memory loss C. Slurred speech D. Elevated temperature 17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? A. Loose stools B. Jitteriness C. Hypertonia D. Abdominal distention 18. A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? A. Hgb 12.5 g/dl B. Platelets 250,000/mm3 C. Hct 40% D. WBC 14,000/mm3 19. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? A. “The proxy should make health care decisions for the client regardless of the client’s ability to do so.” B. “The proxy can make financial decisions if the need arises.” C. “The proxy can make treatment decisions if the client is under anesthesia.” D. “The proxy should manage legal issues for the client.” 20. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? A. Turn the client on their side. B. Administer an analgesic C. Administer antiemetic D. Monitor the client’s vital signs. 21. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the client’s perception of the event B. Notify the client’s support system C. Help the client identify personal strengths D. Teach the client relaxation techniques 22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client’s peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client’s condition every 15 minutes. 23. A nurse is caring for a client who has end-stage of kidney disease. The client adult child asked about becoming a living donor for his father. Which of the following condition 24. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a staffing shortage. Which of the following client should the nurse delegate to the LPN? A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs. B. A client who sustained a concussion and has unequal pupils. C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. D. A client who fractured his femur yesterday and is experiencing shortness of breath. 25. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? A. Place the client upright on a donut-shaped cushion B. Teach the client to shift his weight every 15 min while sitting C. Turn and reposition the client every 3 hr while in bed D. Assess pressure points every 24 hr 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management (Unable to read) a safe option for the client? A. Naloxone hydrochloride. B. Spinal anesthesia. C. Pudendal block. D. Butorphanol tartrate. 26. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan the right to see objects on the right side of her body. b. Place the bedside table on the right side of the bed. c. Orient the client to the food on her plate using the clock method. d. Place the wheelchair on the client’s left side. 27. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?) A. The client changes the subject when future plans are mentioned. B. The client talks about being in pain constantly. C. The client sleeping over 12 hr. each day. D. The client reports giving away personal items. 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) A. Varicella vaccine. B. Inactivated polio vaccine. C. Tetanus diphtheria and acellular pertussis vaccine D. Rubella vaccine. E. Inactivated influenza vaccine. 29. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary glaucoma 30. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 31. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. “I can give you information about respite care if you are interested.” B. “You should consider taking a sleeping pill before bed each night” C. “It must be difficult taking care of someone who is terminally ill” D. “You are doing a great job taking care of your mother” 31. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medications A. Methylprednisolone. B. Ondansetron. C. Guaifenesin. D. Amoxicillin. 32. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? A. “You should take folic acid to decrease the risk of transmitting infections to your baby” B. “You should consume a maximum of 300 micrograms of folic acid every day”. C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. D. “You can expect your urine to appear red-tingled while taking folic acid supplements”. 33. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority? A. Social relationship with peers. B. Plans for attending school while pregnant. C. (Unable to read) (Picked this one) Medicaid? D. Understanding of infant care. 34. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways have unlimited timeframe for completion B. (Unable to read) decrease health care costs. C. (Unable to read) critical pathway if variances (Unable to read) D. (Unable to read) are used to create the critical pathway. 35. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure. 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. “The nurse is legally responsible for the actions of the AP”. B. “An AP can perform tasks outside of his range if he has been trained”. C. “An experienced AP can delegate to another AP”. D. “An RN evaluates the client needs to determine tasks to delegate” 37. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR D. Temperature 37.4C (99.3) 38. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse’s priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. 39. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse’s station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 41. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client’s TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the cline in seclusion when he exhibits signs of anxiety 42. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administered at 2100 D. A client asks for pain medication 1hr early 43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? A. “Does the doctor know you are eating that?” B. “Why are you eating seaweed soup?” C. “Of course I will heat that up for you” D. “The hospital good is more nutritious” 44. a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? A. Leaving a nasogastric tube clamped after administering oral medication B. Documenting communication with a provider in the progress notes of the client’s medical records C. Administering potassium via IV bolus D. Placing a yellow bracelet on a client who is at risk for falls 45. a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Establish a toileting schedule for the client B. Use clothing with buttons and sippers C. Discourage physical activity during the day D. Engage the client in activities that increase sensory stimulation 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? A. “Do you understand that the voices are not real?” B. “Why do you think the voices are talking to you?” C. “Have you tried going to a private place when this occurs?” D. “What helps you ignore what you are hearing?” 48. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? A. Placing a belt restraint on a school-age child who has seizures. B. Securing wrist restraints to the bed rails for an adolescent. C. Applying elbow immobilizers of an infant receiving cleft lip injury D. Keeping the side rails of a toddler’s crib elevated. 49. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 50. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following A. Inject air into the NPH insulin vial. B. (Unable to read) C. Withdraw the prescribed dose of regular insulin D. Withdraw the prescribed dose of NPH insulin 51. a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. “Let’s talk about how you can change your response to stress.” B. “We should establish our roles in the initial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” 51. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse? A. Waits 2 minutes between suctions. B. Encourages the client to cough during suctioning. C. Apply suctioning for 15 seconds. D. Inserts the catheter without applying suction. 53. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 54. A nurse is providing care for a group of clients. Which of the following client’s should the nurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. 55. A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? A. “I will place the eye drops in the center of my eye” B. “I will place pressure on the corner of my eye after using he eye drops” C. “I should expect my tears to turn a red color after using the eye drops.” D. “I should expect the eye drops to appear cloudy.” 56. A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency 57. A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? A. “I would recommend sharing your feelings with a psychologist”. B. “I can give you information about making end of life decisions”. C. “You should discuss your end life decisions with your family” D. “Everyone feels this way at first. You will start feeling better soon”. 58. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep client’s calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. (Limit or remove?) IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech D. Purposeless activity 60. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 61. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1hr if unable to fall asleep B. Take 1 hr nap during the day C. Perform exercise prior to bed D. Eat a light snack before bedtime 62. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. A. nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take? A. Assess the amount of drainage in the collection chamber. B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. 64. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis D. Fever. 65. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? A. “Can you talk about what happens with your partner at home?” B. “Why do you think your partner’s symptoms are progressing so quickly?” C. “You should make sure your partner takes the prescribed medication.” D. “You did the right thing by bringing your partner in for treatment.” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? A. “I will put my child on a gluten-free diet”. B. “I will administer digestive enzymes with meals and snacks”. C. “Provide my child with some high fiber foods.” D. “I will give my child whole wheat toast and milk for breakfast”. 67. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 68. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate? A. 0.9% normal saline. B. NPH insulin. C. Glargine insulin. D. 0.45% saline. 69. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? A. Drink 1.5L fluids each day. B. Take mineral oil at bedtime. C. Increase exercise activity D. Decrease insoluble fiber. 70. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? A. “Drink 2 liters of warm water per day”. B. “Empty your bladder every 6 weeks.”. C. “Soak in a warm bath everyday”. D. “Take an oral estrogen tablet”. 71. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8% 72. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase foods high in gluten 73. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? A. the infant 30 ml (1 oz) glucose water every 2 hr. B. Keep the infants head covered with a cap. C. Ensure that the newborn wears a diaper. D. Apply lotion to the newborn every 4 hr. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. “(Unable to read) I feel to be in his best health care decision” B. “I will intervene if there is conflict between a client and his provider” C. “I should not advocate for a client unless he is able to ask me himself” D. “I will inform a client that his family should help make his health care decisions.” 75. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? A. Raise the side rails on both sides of the client’s bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client’s preferences for determining a reposition schedule. D. Evaluate the client’s ability to help with repositioning. 76. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? A. “ It keeps the alveoli open and prevents atelectasis.” B. “It allows preset pressure delivered during spontaneous ventilation.” C. “It guarantees minimal minute ventilator.” D. “It delivers a preset ventilatory rate and tidal volume to the client 77. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\ 78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 79. A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate the data. 80. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 81. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client’s pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. 82. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians’ Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association 82. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. “The PCA will deliver a double dose of medication when you push the button twice.” B. “You can adjust the amount of pain medication you receive by pushing on the keypad.” C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” D. “You should push the button before physical activity to allow maximum pain control.” 83. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? A. Glargine insulin. B. Regular insulin. C. NPH insulin. D. Insulin aspart. 84. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. (Unable to read) rate of the client’s feedings. D. Instruct the client to move onto their right side. 86. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority? A. Monitor the client’s ECG B. Take the client’s vital signs. C. Administer oxygen D. Insert an IV line. 87. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take? A. Provide information about stress management. B. Maintain a cool temperature in the client’s room. C. Administer epinephrine for acute episodes. D. Give glucocorticoid steroid twice per day. 88. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factor for angina? A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. 89. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? A. Bisacodyl 10 mg rectal suppository. B. Magnesium hydroxide 30 ml PO. C. Famotidine 20 mg PO. D. Loperamide 4 mg PO. 90. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? A. Contact the client’s family about the incident. B. Notify the client’s provider about the incident. C. File a complaint with the facility’s ethics committee. D. Report the incident to the AP’s charge nurse. 91. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? A. Withhold all medications until after dialysis B. Rehydrate with dextrose 5% in water for orthostatic hypotension. C. Check the vascular access site for bleeding after dialysis. D. Give an antibiotic 30 min before dialysis. 92. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority? A. Develop a safety plan with the client B. (Unable) options for reporting the incident. C. Refer the client to a community support group. D. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis 94. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea. 95. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation therapy C. A client who is receiving heparin for deep-vein thrombosis D. A client who is 1 day postoperative following a vertebroplasty 96. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number) 6 mL/hr 97. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? A. “This test should be performed after your baby is 24 hours old.” B. “A nurse will draw blood from your baby’s inner elbow.” C. “Your baby will be given 2 ounces of water to drink prior to the test.” D. “This test will be repeated when your baby is 2 months old.” 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? A. “My stool will become fully formed within 3 weeks” B. “My skin will need to be cleaned with alcohol before I apply a new pouch” C. “I should avoid eating popcorn and fresh pineapple” D. “I should expect bruising around the stoma” 99. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse’s priority? A. Refer the client to a speech language pathologist. B. Monitor the client’s prealbumin levels C. Measure the client’s weight. D. Place the client on NPO status. 100. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 101. A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client’s current pain level. D. Instruct the client about dietary restrictions. 102. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 103. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. “I cannot be a witness for your consent to donate.” B. “Your name cannot be removed once you are listed on the organ donor list.” C. “Your desire to be an organ donor must be documented in writing.” D. “You must be at least 21 years of age to become an organ donor.” 104. A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily. 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist 109. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? A. Return unopened equipment to the supply center B. Leave the unused infusion pump in the room until discharge C. Stock the room with a 2-day supply of disposable diapers D. Being in formula as needed 108. A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? A. Hear rate 100/min B. Temperature 37.8C (100F) C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3 109. A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. B. Use 7th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables. 110. A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide? A. “Add salt to season” B. “Ice chips” C. “Rinse your mouth with an alcohol-based mouthwash” D. “Eat foods served at hot temperatures” 111. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions 112. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 113. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) A. Identify family needs interventions using the nursing process. B. Record information about the home visit according to agency policy. C. Contact the family to determine availability and readiness to make an appointment D. Discuss plans for future visits with the family. E. Clarify the reason for the referral with the provider’s office. E C A B D (My choice) 114. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? A. A residual of 65mL 1 hr postprandial B. A History of gastroesophageal reflux disease C. Sitting in a high-Fowler’s position during the feeding D. Receiving a high osmolarity formula 116. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take magnesium hydroxide for indigestion B. Drink at least 3L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in potassium 118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block B. Premature ventricular contraction. C. Sinus bradycardia. D. Atrial fibrillation. 119. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? A. Provide the client with an instructional handout about swallowing exercises. B. Ask a speech therapist to evaluate the client’s ability to swallow. C. Discuss the manifestations of impaired swallowing with the AP. D. Listens to the client’s lung sounds. 120. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing B. Encourage the client to lie down in a quiet room C. Avoid eye contact with the client D. Refer to the hallucinations as if the are real 120. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? A. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease” B. “There is no need to have genetic counseling if I know that I have a family history of mental illness.” C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” D. “Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.” 121. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? A. “The cord stump will fall off in 5 days.” B. “Contact the provider if the cord stump turns black.” C. “Clean the base of the cord with hydrogen peroxide daily.” D. “Keep the cord stump dry until it falls off.” 122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? A. “I have my eyes examines annually” B. “I take a calcium vitamin supplement daily” C. “I limit my intake of foods with potassium” D. “I constantly take my medication between 8 and 9 each evening” 123. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? A. Stands with feet together when lifting a client up in bed. B. Raises the client’s head of bed before pulling the cline up. C. Uses a mechanical lift to move client from bed to chair. D. Places a gait belt around the client’s upper chest before assisting a client to stand. 124. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? A. “Your bladder should be full prior to me performing this test B. “If this test is positive you will be required to have a non-stress test. C. “This test will determine if there is leaking amniotic fluid” D. “I will be taking a blood sample to test for changes in your hormones levels” 125. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema B. Increased thirst. C. Flattened neck veins. D. Hypotension 126. A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first? A. Document clinical findings. B. Contact child protective services. C. Refer the parents to a self-help group. D. Instruct the parents about methods of discipline. 127. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? A. Encourage the client to floss daily. B. Remove fresh flowers from the client’s room. C. Provide the client what a stool softener. D. Avoid serving the client raw vegetable. 128. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 129. (Unable to read) A. Use NPH insulin to treat ketoacidosis. B. Administer NPH insulin 30 minutes before breakfast. C. (Unable to read) I think this answer was 0.9% sodium chloride D. Discard the NPH insulin vial if the medication is cloudy. 131. A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? A. Maintain the client’s oxygen saturation level at 89%. B. Place the client’s lower extremities on two pillows. C. Recommended that the client follow a 3g sodium diet. D. Place the client in high fowler’s position. 132. A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include? A. “You will need to monitor the client’s electrolytes daily” B. “You will need to change the IV dressing site once per week” C. “You will need to warm the solution in the microwave before administration” D. “You need to weigh the client twice per week” 133. A nurse is teaching a prenatal class about infection at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” B. “I can clean my cat’s litter box during my pregnancy.” C. “I should take antibiotics when I have a virus.” D. “I should wash my hands for 10 seconds with hot after working in the garden.” 133. A nurse is caring for a client who has end-stage liver cancer. Which of the following statements should the nurse make to support the client’s right to autonomy? A. “You should trust that your care team has your best interest at heart” B. “I will not share any personal information without your permission C. “The health care team will do their best to keep any promise we make to you” D. “We encourage you to participate in all decisions about your treatment” 134. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. 136. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 137. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violet. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender 137. A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? A. Inform clients about the action of each medication prior to administration. B. (Unable to read) two times prior to administration. C. Complete an incident report if a client vomits after taking a medication. D. Avoid preparing medications for more than two clients at one time. 138. A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Takes assigned breaks at regular intervals B. Documents the clients care tasks at the end of the shift. C. assisting with ADLs to perform time sensitive activities D. Gather necessary supplies before beginning a dressing change. 139. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 140. A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client’s fundus? C 142. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. “The client might act seductively.” B. “The client is overly concentrated about minor details.” C. “The client exhibits impulsive behaviors.” D. “The client is exceptionally clingy to others.” 142. A nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) A. Aspirin B. Magnesium sulfate C. Gingko biloba. D. Cetirizine E. Ibuprofen. 143. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritual behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging 144. A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb) and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of the following? A. 23 B. 42 C. 32 D. 8 145. A nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? A. The child expresses curiosity about the death process. B. The child refuses to talk about death. C. The child believes the person will return. D. The child focuses on his own mortality. 146. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? Exhibit 1 Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance Exhibit 2 History and Physical Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic. Exhibit 3 Vital Signs BP 166/96 mm Hg Respiratory rate 24/min Pulse rate 112/min Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9 A. Place the client on a cooling blanket. B. Administer an analgesic. C. Obtain arterial blood gas levels. D. Elevate the head of the client’s bed 30 degrees. 147. A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? A. Decreased hematocrit. B. Increased blood pressure. C. Tachycardia. D. Hypothermia. 148. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? A. “Use a vein in the middle of the lower arm to insert a PICC.” B. “Flush a PICC using a 3-milliliter syringe.” C. “Informed consent is required prior to PICC placement.” D. “Position the client’s arm in adduction for PICC placement.” 149. A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete? A. Furosemide 20 mg BID B. Nitroglycerin transdermal patch. C. Aspirin 1 tablet daily. D. Metoprolol 5mg IV now. 150. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussion on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure D. Perform the procedure prior to meals 151. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L 152. A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? A. “The lactation amenorrhea method is effective for your first year postpartum” B. “You can continue to use the diaphragm used before your pregnancy” C. “Place transdermal birth control patch on your upper arm” D. “I should avoid vaginal spermicides while breast feeding.” 153. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in the hallway” 154. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Restrict the client’s total fluid intake to 250 mL/hr B. Give the protamine if signs of magnesium sulfate toxicity occur C. Monitor the FHR via Doppler every 30min D. Measure the client’s urine output every hour 155. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 156. A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. 157. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 158. recieves a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? A. “Have your child lie down and turn their head to their side for 10 minutes” B. “Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s nose” C. “Place a warm wet washcloth over your child’s forehead and the bridge of their nose” D. “Tell your child to blow their nose gently and then sit down and tilt your head back” 159. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. 160. A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications? A. Zolpidem 10mg PO one tablet at bedtime B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Lorazepam .5mg PO one tablet daily 161. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client’s behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client’s behavior once every hour. 162. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 163. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? A. (Unable to read) B. (Unable to read) C. Grasp the IV pump cord when unplugging it from the electrical outlet. D. (Unable to read) outlet has two prongs for the IV pump. 164. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should the nurse anticipate? A. Clamp the (Unable to read) B. Administer fluid bolus. C. Obtain a urine specimen for culture and sensitivity D. Initiate continuous bladder irrigation. 165. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. Heart rate 58/min B. Fasting blood glucose 100 mg/dL C. Hgb 14 g/dL D. WBC count 2,900/mm3 166. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 167. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia. 168. A client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse nutritional requirements? A. (Unable to read) (Chose this one) B. Keep a calorie count for food and beverages. C. Schedule meals at 6 hr. intervals D. Provide low-protein high carbohydrate diet 169. D 170. A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine. The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine? A. (Unable to read B. Client has (Unable to read) HIV/AIDS C. Client has a sensitivity to eggs. D. Client is experiencing seasonal allergies. 171. A nurse is providing teaching about digoxin administration to the parents of a toddler which as heart failure. Which of the following statements should the nurse include in the teaching? A. “Limit your child’s potassium intake while she is taking this medication.” B. “You can add the medication to a half-cup of your child’s favorite juice.” C. “Repeat the does if your child vomits within 1 hour after taking the medication.” D. “Have your child drink a small glass of water after swallowing the medication.” 171. A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a 1-month-old infant. Which of the following indicates that the parent understands how to place the infant in the crib at bed time? B 172. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take? A. Obtain the specimen immediately upon the client waking up. B. Wait 1 day to collect the specimen if the client cannot provide sputum. C. Ask the client to provide 15 to 20 ml of sputum in the container. D. Wear sterile gloves to collect specimen from the client. A. nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? A. Digoxin 0.8 ng/ml B. Sodium (Was out of range) C. BUN 15 D. Potassium 3.1 mEq/L. 174. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 175. A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming.” B. “This type of seizure lasts 30 to 60 seconds.” C. “The child usually has an aura prior to onset.” D. “This type of seizure has a gradual onset.” 176. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete 177. A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications? A. aPTT. B. Pyro (Unsure if that’s the writing) C. Platelet count. D. INR. 178. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? A. Identify solutions prior to negotiation B. Focus on how the conflict occurred C. Attempts to understand both sides of the issue D. Personalize the conflict 179. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. 180. A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? A. Tachycardia. B. Narrowed pulse pressure. C. Hypotension. D. Increasingly severe headache. 1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. 2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D. Constipation for 2 days. 3. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take? A. Arrange for an ethics committee meeting to address the family’s concerns. B. Support the family’s decision and initiate life-sustaining measures. C. Complete an incident report. D. Encourage the family to contact an attorney. 4. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. D. Wear a mask when changing the linens in the client’s room. 6.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. 7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D.Hypocalcemia. 8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client’s understanding of life-sustaining measures. C. Determine the client’s preferences about post mortem care. D. Request a conference with the client’s family. 9.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing. 10.A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the .following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. Instruct the client to lie on his right side. 11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority? A. Psychologist. B. Social worker. C. Occupational therapist. D. Speech-language pathologist. 12.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. Erythrocyte sedimentation rate 75 mm/hr 13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin. 14. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. 15. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. 16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. 17. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. 18. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client’s mouth when he is ready to eat. B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. Place the client’s left arm on a pillow while he is sitting. 19. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. 20. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? B. Limit the client’s visitors to 30 min per day. C. Discard the client’s linens in a double bag. Discard the radioactive source in a biohazard bag 21. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea 22. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation. C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100) D. Chorioamnionitis 23. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. D. Jugular vein distention. E. Weight gain. D.Brady pnea 24. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 25. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 26. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors. 27. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia. 28. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse. 29. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April . Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.) 0119 date 30. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42) C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 31. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching. UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” B. “Given 2 mg MSO4 IM for report of pain” C. “Dressing changed qd” D. “Administered 8 u regular insulin sq.” 32. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Apply pressure to the lacrimal punctum. 2. Ask the child to look upward. 3. Pull the lower eyelid downward. 4. Instill the drops of medication. 5. Place the child in a sitting position. 52341 33. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. 34. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? ON THE REPORT needs double checking A. Urine output 20 ml/hr. B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. D. Contractions every 5 min that last 30 seconds. 35.A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs. D. Providing crisis intervention through a mobile counseling unit. 36. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. 37. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? B. “I noticed that I am having a harder time holding on to my toothbrush” C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” D. “Sometimes, I feel I am making a chewing motion when I’m not eating” 38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. 39. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? B. “I recommend that you take this medication as prescribed” C. “Do you know why this medication is being prescribed to you?” D. “I will call the pharmacist now to check on this medication” 40 A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 41. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. 42. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report? A. Herpes simplex. B. Human papillomavirus C. Candidiasis D. Chlamydia 43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 44. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 45. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 46.A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. 48. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 50. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 52. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 53. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 54. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. 55. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 56. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 66. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in the hallway” 57. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 58. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? 59. A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 60. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux” D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. 62 C 63 A 64. C 65. D 66.C . 68.B 69.A 70.C 71.D 72.C 73.D 74.C 75.A 76.C 77.C 78.B 79. C 80. D 81. A 82 B 83. A 84. A 85. A 86. C 87 A 88. C 89. D 90. C 91. A 92. A 93. A 94. A 95. C 96 C 97 D 98. D 99. D 100. D 101. A 102. B 103. B 104. D 106 A 107. D 108. B 109. C 110. B 111. D 112. C 113. B 114. C 115. A 116. D 117. B 118. D 119. D 120. A 121. C 122. A 123. A 124. C 125. D 126. D 127. Intradermal Injection areas A. Buttocks. B. Upper back. C. Hamstring area. 128.A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) a. Impulse control difficulty b. Left hemiplegia c. Loss of depth perception d. Aphasia e. Lack of situational awareness 128.A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? f. Teach the client to scan the right to see objects on the right side of her body. g. Place the bedside table on the right side of the bed. h. Orient the client to the food on her plate using the clock method. i. Place the wheelchair on the client’s left side. 129.A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) j. Have suction equipment available for use. k. Feed the client thickened liquids. l. Place food on the unaffected side of the client’s mouth. m. Assign an assistive personnel to feed the client slowly. n. Teach the client to swallow with her neck flexed. 130.A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client’s plan of care? (Select all that apply.) o. Speak to the client at a slower rate. p. Assist the client to use flash cards with pictures. q. Speak to the client in a loud voice. r. Complete sentences that the client cannot finish. s. Give instructions one step at a time. 131.A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? t. Impulse control difficulty u. Poor judgement v. Inability to recognize familiar objects w. Loss of depth perception 132.A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. Position the client in an upright position, leaning over the bedside table. b. Explain the procedure. c. Obtain ABG’s. d. Administer benzocaine spray. 133.A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? e. Respiratory acidosis f. Respiratory alkalosis g. Metabolic acidosis h. Metabolic alkalosis 134.A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? i. Blood-tinged sputum j. Dry, nonproductive cough k. Sore throat l. Bronchospasms 135.A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room? (Select all that apply.) m. Oxygen equipment n. Incentive spirometer o. Pulse oximeter p. Sterile dressing q. Suture removal kit 136.A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) r. Dyspnea s. Localized bloody drainage on the dressing t. Fever u. Hypotension v. Report of pain at the puncture site 137.A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? (Select all that apply.) a. Oxygen b. Sterile water c. Enclosed hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing 138.A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? f. Obtain a chest x-ray g. Apply sterile gauze to the insertion site. h. Place tape around the insertion site. i. Assess respiratory status. 139.A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) j. Continuous bubbling in the water seal chamber k. Gentle constant bubbling in the suction control chamber l. Rise and fall in the level of water in the water seal chamber with inspiration and expiration m. Exposed sutures without dressing n. Drainage system upright at chest level 140.A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? o. Lie on it left side. p. Use the incentive spirometer. q. Cough at regular intervals. r. Perform the Valsalva maneuver. 141.A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) s. Encourage the client to cough every 2 hours. t. Check the continuous bubbling in the suction chamber. u. Strip the drainage tubing every 4 hours. v. Clamp the tube once a day. w. Obtain a chest x-ray. 142.A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? a. “It keeps the alveoli open and prevents atelectasis.” b. “It allows preset pressure delivered during spontaneous ventilation.” c. “It guarantees minimal minute ventilator.” d. “It delivers a preset ventilatory rate and tidal volume to the client.” 143.A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) e. Confusion f. Pale skin g. Bradycardia h. Hypotension i. Elevation blood pressure. 144.A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? j. Apply a vest restraint if self-extubation is attempted. k. Monitor ventilator settings ever 8 hours. l. Document tube placement in centimeters at the angle of jaw. m. Assess breath sounds every 1 to 2 hours. 145.A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? n. Nonrebreather mask o. Venturi mask p. Nasal cannula q. Simple face mask 146.A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the plan of care? (Select all that apply.) r. Assist-control s. Synchronized intermittent mandatory ventilation t. Continuous positive airway pressure u. Pressure support ventilation v. Independent lung ventilation 146.A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) a. Client who has dysphagia b. Client who has AIDS c. Client who was vaccinated for pneumococcus and influenza 6 months ago d. Client who is postoperative and received local anesthesia. e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis 148.A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority? g. Obtain baseline vital signs and oxygen saturation. h. Obtain a sputum culture. i. Obtain a complete history from the client. j. Provide a pneumococcal vaccine. 149.A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. k. Administer antibiotics. (3) l. Administer oxygen therapy. (1) m. Perform a sputum culture. (2) n. Administer an antipyretic medication to promote client comfort. (4) 150.A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? o. Percussion of posterior lobes of lungs p. Auscultation of the trachea q. Inspection of the conjunctiva r. Palpation of the orbital areas 151.A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? s. “I should wash my hands after blowing my nose to prevent spreading the virus.” t. “I need to avoid drinking fluids if I develop symptoms.” u. “I need a flu shot every 2 years because of the different flu strains.” v. “I should cover my mouth with my hand when I sneeze.” 152.A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) a. SaO2 95% b. Wheezing c. Retraction of sternal muscles d. Pink mucous membranes e. Premature ventricular complexes (PVC’s) 153.A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? f. Antibiotic g. Beta-blocker h. Antiviral i. Beta2 agonist 154.A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? j. “I will decrease my fluid intake while taking this medication.” k. “I will expected to have black, tarry stools.” l. “I will take my medication with meals.” m. “I will monitor for weight loss while on this medication.” 155.A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? n. Gender o. Environmental allergies p. Alcohol use q. Race 156.A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? r. “This medication can decrease my immune response.” s. “I take this medication to prevent asthma attacks.” t. “I need to take this medication with food.” u. “This medication has a slow onset to treat my symptoms.” 157.A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates and understanding of the teaching? a. “This medication can increase my blood sugar levels.” b. “This medication can decrease my immune response.” c. “I can have an increase in my heart rate while taking this medication.” d. “I can have mouth sores while taking this medication.” 158.A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) a. Hypokalemia b. Tachycardia c. Fluid retention d. Nausea e. Black, tarry stools 159.A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? a. “There are portable oxygen delivery systems that you can take with you.” b. “When you go out, you can remove the oxygen and then reapply it when you get home.” c. “You probably will not be able to go out at much as you used to.” d. “Home health services will come to see you so you will not need to get out.” 160.A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. “I will place the adapter on my finger to read my blood oxygen saturation level.” b. “I will lie on my back with my knees bent.” c. “I will rest my hand over my abdomen to create resistance.” d. “I will take in a deep breath and hold it before exhaling.” 161.A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? a. Take quick breaths upon inhalation. b. Place you hand over your stomach. c. Take a deep breath in through your nose. d. Puff your cheeks upon exhalation. 162.A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.) a. “I can substitute one medication for another if I run out because that all fight infection.” b. “I will wash my hands each time I cough.” c. “I will wear a mask when I am in a public area.” d. “I am glad I don’t have to have any more sputum specimens.” e. “I don’t need to worry where I go once I start taking my medications.” 163.A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. “You will need to continue to take the multi-medication regimen for 4 months.” b. “You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.” c. “You will need to remain hospitalized for treatment.” d. “You will need to wear a mask at all times.” 164.A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. “Your urine can turn a dark orange.” b. “Watch for a change in the sclera of your eyes.” c. “Watch for any changes in vision.” d. “Take vitamin B6 daily.” 165.A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. “You might notice yellowing of your skin.” b. “You might experience pain in your joints.” c. “You might notice tingling of your hands.” d. “You might experience loss of appetite.” 166.A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum 167.A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? (Select all that apply.) a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation 168.A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? (Select all that apply.) f. Bradypnea g. Pleural friction rub h. Hypertension i. Petechiae j. Tachycardia 169.A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? k. Notify the provider. l. Administer heparin via IV infusion. m. Administer oxygen therapy. n. Obtain a spiral CT scan. 170.A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? o. “I am allergic to morphine.” p. “I take antacids several times a day.” q. “I had a blood clot in my leg several years ago.” r. “It hurts to take a deep breath.” 171.A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? a. Hip arthroplasty 2 weeks ago b. Elevated sedimentation rate c. Incident of exercise-induced asthma 1 week ago d. Elevated platelet count 172.A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) a. Tachypnea b. Deviation of the trachea c. Bradycardia d. Decreased use of accessory muscles e. Pleuritic pain 173.A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? a. Assess the client’s pain. b. Obtain a large-bore IV needle for decompression. c. Administer lorazepam. d. Prepare for chest tube insertion. 174.A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? a. “Notify the provider if you experience weakness.” b. “You should be able to return to work in 1 week.” c. “You need to wear a mask when in crowded areas.” d. “Notify your provider if you experience a productive cough.” 175.A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) a. Bradycardia b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxic chest movement 176.A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first? a. Obtain a chest ex-ray. b. Prepare for chest tube insertion. c. Administer oxygen via high-flow mask. d. Initiate IV access. 177.A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? e. “This medication is given to treat infection.” f. “This medication is given to facilitate ventilation.” g. “This medication is given to decrease inflammation.” h. “This medication is given to reduce anxiety.” 177.A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) a. A client who experienced a near-drowning incident b. A client following coronary artery bypass graft surgery c. A client who has a hemoglobin of 15.1 mg/dL d. A client who has dysphagia e. A client who experienced a drug overdose 178.A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) a. Administer antibiotics. b. Provide supplemental oxygen. c. Administer antiviral medications. d. Administer bronchodilators. e. Maintain ventilatory support. 179.A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) a. Fentanyl b. Furosemide c. Midazolam d. Famotidine e. Dexamethasone 180.A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? a. “Air should be instilled into the monitoring system prior to the procedure.” b. “The client should be positioned on the left side during the procedure.” c. “The transducer should be level with the second intercostal spaced after the line is placed.” d. “A chest x-ray is needed to verify placement after the procedure.” 1) A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how often do you drink alcohol d) Tell me about your school schedule 2) *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene? a) Holding the newborn in an en face position b) Asking the father to change the newborn's diaper c) Requesting the nurse take the newborn nursery so she can rest d) Viewing the newborn’s actions to be uncooperative 3) A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the medication is effective? a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism) b) Decreased blood pressure c) Absence of seizures d) Decrease inflammation 4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching? a) Contact provider if the cord still turns black (it’s going to turn black) b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection) d) The cord stump will fall off in five days (cord falls off in 10-14 days) 5) A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? a) Shivering b) Oliguria c) Bradypnea d) Constricted pupils 6) A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client 2 of 28 should the nurse identify as the priority? a) A client that has massive head trauma b) A client has full thickness burns to face and trunk c) A client with indications of hypovolemic shock d) A client with open fracture of the lower extremity 7) A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first? a) A client who has illeal conduit and mucus in the pouch b) Client pleasant arteriovenous additional vibration palpated c) A client whose chronic kidney disease with cloudy diasylate outflow d) A client was transurethral resection of the prostate with a red tinged urine in the bag 8) A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention? a) Place’s cardiac monitoring b) Monitor the clients oxygen saturation level c) Provide standby assist with the client from bed d) Encourage foods high in potassium 9) A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect? a) Feta hypoxia b) Abrupto placentae c) Post maturity d) Head Compression 10) A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis? a) glomerular filtration rate of 14 mL/ minute b) BUN 16 mg/DL c) serum magnesium 1.8 mg mg/dl d) Serum phosphorus 4.0 mg/dL 11) A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take? a) Placed infant under radiant warmer b) Move the probe site every 3 hours c) Heat the skin one minute prior to placing the program d) Placed a sensor on the index finger 12) A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first? a) Client placed in restraints to the aggressive behavior b) A new limited client pleasures history of 4.5 kg weight loss in the past two months c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety d) Applied he’ll be receiving his first ECT treatment today 13) A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? a) Hypnosis focuses on the biofeedback as a relaxation technique b) Hypnosis promotes increased control of her pain perception during contractions c) Hypnosis uses therapeutic touch to reduce anxiety during labor d) Hypnosis provides instruction to minimize pain 14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone you dislike) a) I steal things because it’s the only way I can keep my mind off my bad marriage b) I can’t believe I was accused of something I didn’t do c) I don’t want talk about my feelings right now. We will talk more next time d) I think that people just you’re just lazy and should earn money honestly 15) A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate. Which of the following should the nurse identify as a contraindication to medication? a) Glaucoma b) Hypertension c) Polycythemia d) Migraine headaches 17) The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care? a) Draw a troponin level every four hours b) Performance EKG every 12 hours c) Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitation consult 18) A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider? a) WBC 3,000/mm3 b) Hemoglobin 14 g/dl c) Platelet 250,000/mm3 d) aPTT 30 seconds 19) Home health nurse is carefully planned for Alzheimer’s disease. To the following action should the nurse include in the plan of care a) Place a daily calendar in the kitchen b) Replace button clothing with zippered items c) Replace the carpet with hardwood floors d) Create variation in daily routine 20) Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first? a) The client was cystic fibrosis and has a thick productive clock and reports thirst b) Client who has gastroenteritis and is lethargic and confused c) The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over deal d) The client was sick of signing it reports pain 15 minutes after receiving oral analgesic 21) A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate? a) Decrease taking vitamins and supplements to every other day b) Eat 15 g of fiber per day c) Consume 48 ounces of water each day (need at least 64 oz) d) Drink hot water with lemon juice each morning when you wake up 23) A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply a) I can’t change my instructions once a minute b) My doctor will need to approve my advance directives c) I need an attorney to witness my signature on the advance directives d) I have the right to refuse treatment e) My health care proxy can make medical decisions for me 24) A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output? a) The chest b) Standing c) Supine d) Left lateral 25) A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP? a) Client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry b) Client who has awoken following a bronchoscopy and requests a drink c) Client who had a myocardial infarction 3 days ago reports chest discomfort d) Client who had a cerebrovascular accident two days ago and needs help toileting 26) Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? a) Constipation b) blurred vision c) Fever d) Dry Mouth 27) A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention? a) Providing a high protein snack b) Assisting the child to reposition c) Placing weights as a child’s bed d) Massaging pressure points-causes skin breakdown 28) A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take? a) Determine if the AP is qualified to perform the test. b) Help the AP performed the blood glucose test c) Assign the AP to ask the client is taking his diabetic medication today d) Have AP check the medical record for prior blood glucose test results 29) A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following? a) Alzheimer’s disease b) Schizophrenia c) Substance intoxication d) Depression 30) A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are associated with this diagnosis? Select all that apply a) splenomegaly b) Koplik spots (this is associated with measles) c) Malaise d) Vertigo e) Sore throat 31) Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first? a) Apply skin preparation to wound edges. b) Normal saline c) Don sterile gloves d) Determine pain level 32) A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly? a) Drainage fluid is greenish-yellow b) aspirate pH of 3 c) Abdominal rigidity d) air bubbles noted in the NG tube 33) A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take? a) Piggyback 0.9 sodium chloride with TPN solution b) Check for an allergy to eggs c) Discuss the TPS solution for 12 hours d) Monitor for hypoglycemia 34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?) a) Systemic analgesic effect b) increase in your metabolism c) Decreased capillary permeability d) Vasodilation 35) Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to a) Perform weight bearing exercises b) Avoid crossing the legs beyond the midline c) Avoid sitting in one position for prolonged periods d) Split affected area 36) A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign b) A client who was Clostridium difficile with acute diarrhea c) A client who is acute kidney injury and urine with a low specific gravity d) The client who has oral cancer and reports a sore on his gums 37) Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate? a) Call the provider to clients respiratory rate is less 18/min b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr c) Give the client enalapril 2.5 mg PO twice daily d) Call the provider if the clients pulse rate is less than 80/min 38) A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan? a) I will be able starting this medication with feel better b) I can expect to urinate frequently while on this medication c) I understand I may experience difficulty sleeping on this medication d) I should decrease my sodium intake while on this medication 39) A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?” a) Offer to speak to the client’s husband regarding his abuse behavior. b) Help the client to recognize the signs of escalation of abuse behavior c) Assist the client to identify personal behaviors that trigger abusive behavior d) Assist the client to Reports abusive behavior to the proper authority 40) A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? a) Why do you think your life is not worth it anymore? b) Do you have a plan to end your life? c) I need to know what you mean my misery d) You can trust me and tell me what you’re thinking 41) A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect? a) Decreased level consciousness b) Unable to identify common objects c) Poor problem solving ability d) Preoccupation was somatic disturbances 42) A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take? There are 3 tabs that contain separate categories of data. a) Position the client with the affected extremity lower than the heart b) Administration of acetaminophen c) Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion 43) Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse? a) Expel air bubble at the top of the prefilled syringe b) Massage the injection site to evenly distribute the medication c) Inject the medication the lateral abdominal wall d) Administer an NSAID for injection site discomfort 44) Nurses caring for four clients. Which of the following client data should the nurse report to the provider? a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing b) Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hour following surgery c) Client who is 4 hrs postoperative and has a heart rate of 98 per minute d) The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 45) Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client? a) Promethazine b) Hydromorphone c) Ketorolac d) Amitriptyline 46) A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care? a) Live with the clients fluid intake to 1500 mL per day b) Massage place affected extremity to relieve pain c) Apply cold packs of clients affected extremity d) Elevate the client’s affected extremity when in bed 47) A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take? a) Discontinue oxytocin infusion b) Increased oxytocin infusion c) Decreased oxytocin infusion d) Maintain oxytocin infusion 48) A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client? a) Have your membranes ruptured? b) How far apart are your contractions? c) Do you have any active lesions? d) Are you positive for beta strap? 49) Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should the nurse include? a) Take with meals b) Take at bedtime c) Take with a glass of milk d) Take with a glass of orange juice 50) Four clients present to the emergency department. The nurse should plan to see which of the following clients first? a) A 6 year old client whose left shoulder is dislocated b) A 26 year old client for sickle cell disease and a severe joint pain c) A 76 year old client was confused, febrile and has foul smelling urine - uti d) A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke 51) A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find? a) Leavened bread maybe eaten during Passover. b) Shellfish is commonly consumed in the diet. c) Meat and dairy products are eaten separately. d) Fasting from meat occurs during Hanukkah. 52) ? 53) A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply a) Apply direct pressure to bleeding wounds b) Clean rest last rations and abrasions with hydrogen peroxide c) Cover wounds with a sterile dressing d) Administer 650 mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid vaccination. 54) The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation? a) Sodium 138 b) Creatinine 1.8 c) Hemoglobin 15 d) Potassium 4.2 55) A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching? a) I understand the methadone tends to slow my breathing b) I understand the methadone may cause me to have difficulty sleeping c) I will avoid alcohol while I’m taking this medication d) I’ll change positions gradually especially from lying down to standing 56) Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation? a) Premature infant with a poor suck reflex and failure to thrive b) An older adults who has difficulty taking in fluids c) Adolescent who anorexia who is cachectic d) A middle aged adults was gastroesophageal reflux disease 57) A nurse is caring for a group of clients. Which of the following client should nurse assess first? a) A client whose benign prostatic hyperplasia and is unable to urinate b) The client was heart failure and report shortness of breath while ambulating c) A client who is open cholecystectomy and has green drainage from the T-tube d) A client whose abdominal pain and is vomiting coffee ground emesis 58) A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure? a) Atorvastatin b) Digoxin c) Nifedipine d) Metformin 59) The nurses assessing client with posttraumatic stress disorder. Which of the following findings to the nurse expect to find? a) Dependence on family and friends b) Loss of interest in usual activities c) Ritualistic behavior d) Passive aggressive behavior 60) A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care? a) Give the client several choices when scheduling activities. b) Confront the client regarding unacceptable behavior c) Maintain Nutritional requirements by offering finger foods d) Stimulate the client by leaving the television on throughout the day 61) A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first? a) A client who has begun to demonstrate catatonic behavior b) The client was compulsive behavior and is frequently drinking from the water fountain c) Client was having auditory hallucinations is becoming agitated d) A client was making sexual comments to clients of the opposite sex 62) A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first? a) Instill erythromycin ophthalmic ointment and the newborn’s eyes. b) Place identification bracelets on the newborn. c) Weigh the newborn. d) Dry the newborn 63) A nurse receives report on a group of clients. Which of the following client should the nurse attend to first? a) A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula b) A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10 c) The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid 64) A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor? a) The client reports the urge to push b) The cervix is dilated 2 cm c) Contractions are 2 to 3 minutes apart d) The client reports nausea and vomiting 65) The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned? a) An AP is to calculate intake and output every two hours for client in acute renal failure. b) An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy c) A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident. 66) A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention? a) pruiritus under the cast b) Localized stabbing pain upon movement c) paresthesia of the distal extremity d) Edema present when leg is in the dependent position 67) The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action? Click on the links of this below for additional client information a) Offer the child a cup of chicken broth. b) Encourage the child’s intake of gelatin. c) Administer oral rehydration solutions. d) Institute a banana, Rice, applesauce, and toast diet. 68) The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? a) Serum chloride b) Uric acid level c) Serum albumin d) Magnesium level 69) A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion? a) Ventricular asystole b) Third-degree AV block c) Atrial fibrillation d) Ventricular fibrillation 70) Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions? a) Scarlet fever b) Herpes simplex c) Varicella d) Streptococcal pharyngitis 71) A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately? a) The clinic experiences coughing and wheezing after eating. b) The client reports abdominal pain at a five on a scale of 0 to 10. c) The client experience is a drop in oxygen saturation to 91% while eating. d) The client reports a burning sensation in epigastric area. 72) A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP? a) Applying condom catheter for client for spinal cord injury b) Administrative oral fluids to client was dysphasia c) Documenting the report of pain from client who is postoperative d) Reviewing active range of motion exercises with a client who is had a stroke 73) A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC? a) Candida albicans b) Herpes simplex virus 2 c) staphylococcus aureus d) Lyme disease 74) The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse? a) A pain score 7 on a scale of 0 to 10 b) Shortness of breath c) New onset of a new enuresis d) Priapism 75) Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse? a) Glascow scale score a 15 b) Blood drainage on initial dressing measuring 3 cm c) Report of dry mouth d) Urinary output greater than fluid intake 76) A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client a) Flexes elbows at 30 degrees when using the handgrips b) Maintains 3 to 4 finger width between the crutch pad and axilla c) Places the crutches 6 inches in front and side of each foot when standing. d) Pushes up from a chair with crutches on the unaffected side. 77) A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? a) Use a designated stethoscope when caring for the toddler. b) Wear an N95 respiratory mask while caring for the toddler. c) Remove the disposable gown after leaving the toddler’s room d) Place the toddler in a room with negative air pressure. 78) A nurse is admitting to a client to emergency department and initiates continuous cardiac monitoring. Which of the following ECG with strips indicates sinus tachycardia? b) 79) A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the plan of care? a) Massage lower extremities daily to prevent DVT b) Limit intake of Food high in calcium to prevent renal calculi. c) Encourage client to lie supine prevent constipation. d) Remove anti embolism stockings for 3 hours each day to decreased skin breakdown. 80) A nurse discovers that the wrong dosage of medication was given to client. When determining what action to take your should recognize that which of the following ethical principles should be applied? a) Utility b) Paternalism c) Veracity d) Fidelity 81) ? 82) A nurse is review in the prescription for doxazosin with a client. Which of the following should be included in the teaching? a) Decrease caloric intake to reduce weight gain. b) Increased dietary fiber to prevent constipation. c) Rise slowly when sitting up from bed. d) Take this medication each morning. 83) Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching? a) Exercising an hour before bedtime b) Take a short nap today c) Keep bedroom cool at night d) Consume a high carbohydrate snack at bedtime. 84) A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions is appropriate? a) Wear a face shield prior into entering the room. b) Place the client private room. c) Place the client in a negative pressure room. d) Use alcohol based hand rub following client care. 85) A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following intervention should the nurse including the plan of care? a) Perform active range of motion exercises. b) Perform neurological checks every 4 hours. c) Suction the airway frequently. d) Maintain the head at a midline position. 86) The nurse is assessing a client is receiving radiation therapy. Which of the following findings should the nurse expect? a) White blood cell count at 12,500 mm3 b) Excessive salivation c) +3 pitting edema d) Platelets 95,000 mm3 87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medications is contraindicated? a) Methylergonovine. b) Misoprostol c) Dinoprostone d) Oxytocin 88) A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect to find? a) Shortness of breath b) Rebound tenderness c) Atypical chest pain d) Vomiting blood 89) A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action? a) Ensure eye shield is covering the eyes. b) Apply lotion to expose skin. c) Offer glucose water between feedings. d) Discontinue breast-feeding during treatment. 90) This is assessing clients as had a long arm cast. Which of the following findings of the dress moderate and when assessing for acute compartment syndrome? a) Shortness of breath b) Petechiae c) Change in mental status d) Edema 91) I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse? a) Placed the client in a prone proposition. b) Implement Positive pressure ventilation. c) Perform nasopharyngeal suctioning. d) administer flumazenil 92) A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actions should the nurse take first? a) Report the AP’s behavior to the supervisor. b) Completed instant report regarding the Aps conversation. c) Provide the AP with written documentation regarding client confidentiality d) Tell the AP to discontinue their conversation 93) A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following? a) testicular Cancer b) Obesity c) Stroke d) Melanoma 94) A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following prescription is given by the provider should the nurse clarify? a) Over the fact that extremities and two pillows. b) Apply heat to affect extremity for 45 minutes on the 45 is off. c) wrap the affected extremity with a compression dressing. d) Assess the affected extremity for sensation movement impulse every four hours 95) A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the following food selections indicates that client understands teaching? a) A sandwich and milkshake b) Rice with black beans c) Cottage cheese and tuna lettuce d) Three egg omelette with low-sodium ham 96) A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a) Remove dirty linens from the room after double bagging. b) Wear a dosimeter film badge while in the client’s room c) Limit each of the clients is yours to one hour per day. d) Ensure family members remain at least 3 feet from the client. 97) A nurses for Caring for four clients. Which of the following client should the nurse care for first? a) A client to receive a chemotherapy treatment or first national b) A client who has an appendectomy to these don’t has diminished all sounds c) A client is hypothyroidism and his stuporous d) A client who is a burn requiring a sterile dressing change 98) The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care? a) Initiate droplet precautions for the client b) Assisted client to supine position c) Performing Glasgow coma scale every 24 hrs d) Recommend prophylactic acyclovir there for the clients family. 99) Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that the teaching has been effective when the client states. a) I want sure that my medications are enteric coated b) My stoma will drain liquid fluid continuously c) I will change my pump system every two weeks d) My stoma size will stay the same even after healed 100) A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to use in combination oral contraceptives? a) thyroid disease b) Allergy to penicillin c) impaired liver function d) abnormal blood glucose 101) The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching? a) This medication can be used to help you when have an acute asthma attack b) This medication should be taken before exercise and physical activity c) This medication can be taken for 10 days and then gradually discontinued d) This medication helps decrease swelling and mucus production 102) I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first? a) A client who is receiving warfarin and has and INR of 3.3 b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL c) A client who had a NG tube inserted 6 hr ago and has abdominal distention d) A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back of the throat 103) A nurse is assessing a client who has pericarditis. Which of the following findings is priority a) Paradoxical pulse pg. 389 under complications b) dependent edema c) Pericardial friction rub d) Substernal chest pain 104) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching? a) Hydrogen peroxide b) Chlorhexidine c) Isopropyl alcohol d) Chlorine bleach 105) *A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take? a) instruct the client to lift her chin when swallowing b) discourage the client from coughing during feedings c) Sit at or below the clients eye level during feedings. d) Talk with the client during her feeding. 106) A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a) Assault b) Battery c) Malpractice d) Negligence 107) A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following? a) Re-Evaluate priorities halfway through the shift b) Delegate changing sterile dressing for licensed practical nurse c) Groups activities for the Same client d) Works on several tasks simultaneously 108) A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority finding? a) Feeling flushed and warm b) Abdominal fullness c) Swollen lips d) Metallic taste in mouth 109) A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate? a) Just the flow rate of the clients oxygen tank b) Collecting urine sample c) Measuring the clients pain level d) Monitoring blood glucose levels 110) A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure? a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92 111) A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report? a) A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump has malfunctioned c) A client who requires insertion of NG tube due to a bowel obstruction d) A client who is absent bell sounds following a gastrectomy 112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor? a) Fasting blood glucose b) Carbohydrate intake c) Hematocrit d) Weight 113) The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse? a) I can wear support bra b) I will play cold compression my breasts c) I will manually express breastmilk d) I can take a mild analgesic 114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity? a) Blood glucose of 150 mg/dL b) Urine output of 20 mL per hour c) Systolic blood pressure at 140 mm Hg d) BUN 20 mg/dL 115) The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following findings are indicative of cold stress? a) Respiratory rate of 60 per minute b) Jitteriness of the hands c) Diaphoretic d) Bounding peripheral pulses in all extremities 116. A nurse is planning care for four clients. Which of the following clients is the highest priority? a. A client who is dry, black eschar on the heel b. A client who is wearing an arm cast and reports numb fingers c. The client was reddened skin area with blanching around the coccyx d. The client who has frequent incontinence 117. A nurse is caring for a male adolescent client who has heart failure. Based on the client’s chart finds. Which of the following actions should the nurse plan to take? a. Withholds spiranolactone b. Administer ferrous sulfate c. Administer furosemide d. Withhold digoxin (0.8-2.0) 118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding? a. Confusion (hypoglycemia) b. Thirst c. Diaphoresis (hypoglycemia) d. Shakiness (hypoglycemia) 119. A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication? a. Eggs b. Milk c. Shrimp d. Peanuts 120. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, “When the cat’s away, the mice will play”. The client response was, “The mice come out when the cat is not around”. The nurse should document this finding which of the following in the client’s chart? a. Echolalia b. Associative looseness c. Neologisms d. Concrete thinking 121. A nurse caring for a client who is receiving total parental nutrition. Which of the following assessment findings required immediate intervention by the nurse? a. prealbumin level of 20 mg/dL b. Weight increase of two kg/day c. Temperature of 37.6°C d. Blood glucose level of 120 mg/dL 122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s been treated for myocardial function. The following is an expected finding for the client? a. Troponin 1 (TNI) 8 ng/ml b. Brain natriuretic peptide (BNP) 10 ng/L c. Alanine aminotransferase (ALT 45 unit/L d. High density lipoprotein (HDL) 75 mg/dl 123. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment? a. paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg c. HCO2 level of 25 mEq/L d. pH level of 7.37 124. A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching? a. "Carbohydrates should be at least 45% of your caloric intake." b. "Protein should be at least 55% of your calorie intake." c. "Carbohydrates should be at least 30% of your caloric intake." d. "Protein should be at least 60% of your caloric intake." 125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? a. 2100 b. 0900 c. 1300 d. 1800 126. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? a. diaphoresis b. polyuria c. abdominal pain d. thirst 127. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? a. Frequency and dysuria b. Profuse milky white discharge c. Hematuria d. Low grade fever 128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding? a. beef broth b. oatmeal c. apple juice d. toast 129. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first? a. A client who reports tingling in the fingers following a thyroidectorny b. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr c. A client who is in a long leg cast and reports cool feet bilaterally d. A client who has a productive cough and an oral temperature of 36° C (96.80 F) 130. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods? a. spinach b. peanut butter c. ground beef d. carrots 131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? a. You only need to receive Rh immune globulin if you have a positive blood type." b. You should receive Rh immune globulin within 72 hours of delivery." c. "Both you and your baby should receive Rh immune globulin at your -week appointment." d. "immune globulin is not necessary since this is your second pregnancy." 132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate? a. You had no way of knowing this would happen." b. Most parents blame themselves when losing a child." c. Tell me why you feel this is your fault." d. You appear to be feeling overwhelmed" 133. A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching? a. “If I eat 500 fewer calories per day, I should lose 1 pound per week.” b. “ If I eat 500 fewer calories per day, I should lose 1 pound per week." c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week." d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week." e. "If I eat 300 fewer calories per day, I should lose 1 pound per week.” 134. A nurses is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching? a. Provide an orthodontic pacifier for comfort. b. Offer fluids by using a straw. c. Cleanse suture line with a cotton tip swab. d. Remove elbow splints periodically to perform range of motion. 135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Perform chest compressions during cardiac resuscitation. b. Perform a dressing change for a new amputee. c. Assess effectiveness of antiemetic medication. d. Provide discharge instructions 136. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox? a. Bloody diarrhea b. Ptosis of the eyelids c. Descending paralysis d. Rash in the mouth 137. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse? a. Aspirate the irrigation solution from the bladder. b. Insert the tip of the irrigation syringe into the catheter opening. c. Apply sterile gloves. 1296 in med surgical book d. open the flow clamp to the irrigating fluid infusion tubing. 138. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication? a. Lipsmacking b. Agranulocytosis c. Clang association d. Alopecia 139. A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care? a. Place the client in seclusion when she is confused. b. Request a prescription for PRN restraints when the client is wandering. c. Dim the lighting in the clients room. d. Leave one side rail up on the clients bed. 140. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management? a. Postorandial blood glucose b. Glycosylated hemoglobin - Ha1c c. Glucose tolerance test d. Fasting blood glucose 141. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? a. Initiate a dietary consult for a toddler. b. Administer a glycerin suppository to a preschool-age child. c. Evaluate gastric residual following intermittent feeding of an adolescent. d. Transport a school-age child to x-ray. 142. A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? a. sodium 130 mEq/L b. Blood pressure 156/90 mm Hg c. Potassium 5.2 mEq/L d. Pulse 54/min 143. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse? a. Apologize to the others for your behavior." b. I am disappointed that you continue to act out when you are angry." c. Come outside with me for a walk." d. If you dont calm down, you will have to go into seclusion." 144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. Which of the following precautions should the nurse take while caring for this client a. Wear an N95 respirator while caring for the client. b. Use a dedicated stethoscope for the client. c. Insert an indwelling urinary catheter to monitor urinary output. d. Monitor the client’s vital signs every 8 hr. 145. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia? a. serum sodium 138 mEq/L b. Urine specific gravity 1.001 c. serum calcium 10 mg/dL d. Urine pH 6 146. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard? a. A client’s wrist restraints tied to the bed rails b. A clients bedside table placed across the foot of the bed c. A meal tray left at the bedside from breakfast d. A call light extension cord pinned to the bedspread 147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response? a. I’d like to know more about what’s bothering you." b. "Why are you feeling this way" c. "You did the right thing by bringing him here." d. "I’m sure your father doesn’t blame you." 148. A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge? a. start each meal with a protein source. b. Consume at least 25 g of fiber daily. c. Check your blood glucose level before each meal. d. Limit your meals to three times per day. 149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? a. Tidaling with spontaneous respirations b. Drainage collection chamber is 1/3 full c. 1 cm of water present in the water seal chamber d. Suction chamber pressure of -20 cm H20 150. A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, “I wonder when the doctor will tell us what’s going on" Which of the following actions should the nurse take first a. Request that the provider provide more information to the family. b. Refer the family to a support group for grief counseling. c. Offer to answer questions that family members have. d. Ask the family what the provider has discussed with them. 151. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is a. scaly and red b. asymmetric, with variegated coloring c. firm and rubbery d. brown with a wart-like texture 152. A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process? a. Decreased sense of taste b. Decreased blood pressure c. Increased gastric secretions d. Increased accommodation to near vision 153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care? a. Administer disulfiram. b. Provide frequent orientation to time and place. c. Engage the client in group therapy. d. Perform gastric lavage. 154. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) a. Top left site 155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult? a. Nursing manager colleagues b. Evidence-based practice data c. Hospital administrators d. Protocols in other hospitals 156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) a. Facial flushing b. Syncope c. Diaphoresis d. Vertigo e. Bradycardia 157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. feelings of dread b. rapid speech c. purposeless activity d. heightened perceptual field 158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task? a. "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place the glucometer into the docking station." b. "Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90." c. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of breath." d. "Turn the client in room 126 to prevent pressure areas on his hip bones." 159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? a. Nicotine withdrawal b. Heroin intoxication c. Alcohol withdrawal d. Amphetamine intoxication 160. A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia? a. Abnormal movements of the mouth b. Inability to stand without assistance c. Paralysis of the right arm d. Loss of appetite 161. *A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include? a. The client should notify the nurse when administering a dose of the medication. b. The client can administer a dose of medication every 6 to 8 min. c. The client should be cautious to avoid overmedication (OD). d. Family members can administer a dose the client. 162. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which of the following actions should the nurse take next a. Document the procedure. b. Measure the drainage. c. Record the color of the drainage. d. Label the specimen. 163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take? a. Notify security to monitor the facility exits. b. Place the client in seclusion. c. Inform the client of the risks involved if she leaves. d. Call the provider for a discharge prescription. 164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration? a. Recent blood transfusion b. Allergy to penicillin c. Minor acute illness d. Low-grade fever 165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? a. Ventrogluteal b. Dorsogluteal c. Vastus lateralis d. Rectus femoris 166. A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI? a. Wearing underwear with a cotton crotch b. Wiping from front to back c. Using perfumed toilet paper d. Urinating immediately after intercourse 167. A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching? a. "I will take my morning pills with food or milk." b. "I will weigh myself every day." c. "I will notify the nurse if I have muscle cramps." d. "I will limit my intake of fish." 168. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? a. hepatits C b. peptic ulcer disease c. bronchitis d. chrohn’s disease 169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care? a. Encourage a diet high in calcium. b. Provide a diet high in potassium. c. Ensure increased fluid intake. d. Restrict protein intake to the RDA. 170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first? a. Take vital signs. b. Assess lochia. c. Massage the fundus. d. Give oxytocin IV bolus. 171. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform a. Give 100 mL of water with every feeding. b. Obtain gastric residuals every 24 hr. c. Position the head of bed at 30 degrees during feeding. d. Mix the clients medications with the tube feedings. 172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective? a. Skin turgor displays tenting b. Flat anterior fontanel c. Cool, mottled skin d. hyperpnea 173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching? a. Remove dye markings after each radiation treatment. b. Apply a warm compress to the irradiated site. c. Wear clothing over the area of radiation treatment. d. Use a washcloth to bathe the treatment area. 174. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective." b. "Take your iron medication with fluids other than coffee or tea." c. "It is important to take your iron medication on a full stomach." d. "If you miss a dose one day, take two doses the next day." 175. 175 A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess a. A client who had a hip arthroplasty reports pain and erythema in his calf b. A client who has anorexia and peripheral edema c. A client who has Addison's disease with a blood glucose level of 75 mg/dL d. A client who had a barium enema 2 days ago and reports constipation 176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer? a. Albuterol sulfate b. Hydromorphone c. Diphenhydramine d. Amitriptyline 177. A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take? a. Ask the assistive personnel to assist the client in signing consent for treatment b. Ask the child to interpret for the client. c. Ascertain what language the client speaks and get an interpreter. d. Try to find an adult relative to help the client communicate. 178. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take? a. Position the client supine. b. Prepare an IV bolus of dextrose 5% in water c. Administer calcium gluconate IV. d. Administer methylergonovine IM. 179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the clients last period was October. What is the expected delivery date? (Provide the date using four numerals, the first two for the month and the second two for the day. For example, January 2 0102) a. 0711 (July 7, 2011) Formula: +1 year, -3 months, +7 days 180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is scheduled for chemotherapy and has a hemoglobin of 9 b. A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP) and has small blood clots in the urinary catheter c. A client who is receiving a blood transfusion and reports low-back pain d. A client who has a new colostomy with a reddish-pink stoma 1. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, “I f you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a. Malpractice b. Battery- physical c. Assault- verbal d. Negligence 2. A nurse is providing discharge instructions to the parent of a newborn. Which of the following statement by the parent indicates an understanding of the teaching? a. I will suction my baby’s mouth before I suction his nose. b. I will lubricate the tip of the syringe with water prior to suction his nose. c. I should insert the syringe into the center of his mouth. d. I should compress the bulb after inserting it into the mouth. 3. A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will place my baby in a forward- facing car seat in my back seat (facing the rear) b. I can place my baby in the front seat with the airbag turned off. (dont put newborn in front) c. I will position my baby at a 45 degrees angle in the car seat. d. I can turn my baby car seat around when she weighs 15 pounds. 4. A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions should the nurse include in the plan for delivery? a. Instill erythromycin ointment into the newborn's eye b. Apply miconazole vaginal cream to the mother prior to delivery c. Give oral sulfadiazine to the mother prior to delivery d. Administer penicillin G procaine IM to the newborn 5. A nurse is planning care for a client who has small-bore NG feeding tube in the jejenum. Which of the following is an appropriate action for the nurse to take to confirm placement? a. Instill two drops of blue food coloring formula b. Review an abdominal x-ray report. c. Verify the glucose level aspirated content. d. Auscultate for bubbling sound while injecting air through the tube.??? - i chose this but ima doble check , i thought about verifying the placement at the moment 6. A charge nurse delegates to an AP the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first? a. Supervise the AP performing the task b. Remind the AP of her assigned tasks. c. Evaluate why the client was not ambulated. Asses the situation first. Y es. assess first d. Ambulate the client on behalf of the AP. Rationale: Care for the client comes first, so ambulate the patient because AP did not. Then you can investigate why AP did not do the task. 7. A nurse is caring for a client who has prescription for lactated ringer’s IV 4080/mL24hr. The nurse should set the IV infusion pump to deliver how many mL/hr to administer half of the total volume in the first 8 hr? Half = 2040 which need to be administered in 8hrs. So 2040ml/8hr = 255ml/hr 8. A nurse is providing teaching to a client who DM about glycosylated hemoglobin blood test. Which of the following statement by the client indicated an understanding of this test? a. I will need to drink a glucose solution to get an accurate result b. I will need to fast prior to taking this test not necessary c. I will use the result of this test daily to modify my insulin dosage. d. I will use this test to monitor how well I control my blood glucose. 9. A nurse is caring for a client who has CVC and develops an air embolism. Which of the following actions should the nurse take? a. Place the client in a left lateral trendelenburg position. b. Prepare the client for chest tube insertion (I put this one. -Jackie) c. Instruct the client to perform valsalva maneuver d. Remove the client catheter. Rationale: Page 98 ATI Med Surg Book. 10. A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following finding is priority? a. THe client reports a pain level of 6 b. The stoma appears dark purple in color c.The colostomy has had no output d. The client refuses to look at the colostomy Rationale: Says notify provider when you see dark purple color which may indicate blood supply is compromised. http://www.atitesting.com/ati_next_gen/skillsmodules/content/ostomycare/equipment/stom a_and_peristo mal_skin_care.html 11. A nurse is caring for a client who has new prescription for enalapril. The client report tingling and swelling around the mouth 1hr after receiving the medication. Which of the following actions should the nurse take first? a. Notify the rapid response team b. Obtain IV access.? ??? - whats that drug that dilates bronchioles that are constricted in case of an anaphylacti RXN ? i thought about that thats why i chose this. c. Document findings d. Elevate the lower extremity. 12. A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid. Which of the following actions should the nurse take? a. Ensure the client has a full bladder just prior to the procedure b. Weight the client before and after the procedure c. Administer a low-volume hypertonic enema the night before the procedure d. Place the client in a side-lying position for the procedure Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective to reduce weight and remove ascites fluid in the abdominal wall. 13. A nurse is admitting a client who tells the nurse he has brought a copy of his advance directives. Which of the following actions should the nurse take? a. Place a copy of the document in the client's medical record. b. Request a social worker to review the document with the client (social worker does not need to review this) c. Ask the client to keep the document in his bedside table. (store it in a safe place) D. Have the provider approve the document. (does not need to be approved by MD) 14. A nurse is providing preop teaching to a client who is scheduled for uterine surgery and asks about the reason for the indwelling urinary catheter. Which of the following responses should the nurse make? a. The catheter will be used to administer pain medication after surgery. (not used for pain medication) b. The catheter will decompress your bladder during surgery. c. The catheter will decrease the risk for UTI from surgery. (risk for UTI) d. The catheter will immobilization after surgery. 15. A nurse is discharging a client who has a colostomy. The client states that she would like to use her moisturizing soap to clean around the stoma. Which of the following responses by the nurse is appropriate? a. It is acceptable to use this soap if it makes you comfortable. b. Lubricants in moisturizing soaps can interfere with adhesion of the appliance c. You may want to try other soaps to determine what is the best to clean around the stoma d. Use of moisturizing soaps can contribute to skin infections. (I put this one -Jackie) Rationale: Page 240 of Funds ATI book Moisturizing soap can interfere with adherence of pouch. 16. A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should the nurse report to the provider? a. ) b. Pulse 140/min c. Abdominal breathing- they are normally abdominal breathers d. Closed anterior fontanel Rationale: page 7 peds 2016 Newborn to 1 year old: RR= 30-35/min 17. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. “ This type of seizure can be mistaken for daydreaming” ( can be brief that sometimes they are mistaken for daydreaming and may not be detected for months) b. b. “The child usually has an aura prior to onset” c.This type of seizure last 30-60 sec” ( begin and end abruptly) d. “This type of seizure has a gradual onset” ( generalized onset) 18. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching? a. The client leans on both crutches to support body weight. (no) b. The client places the crutches 30cm (12in) to the front and side of each foot while standing (6in) c. The client flexes her elbows 10 degree when supporting weight by using the handgrips. (30deg) d. The client keeps her axillae free of pressure. ( yes use your hand for pressure) 19. A nurse is assessing a client who received a Mantoux skin test 72hr ago for TB screening. Which of the following findings indicates a positive test? a. An area of ecchymosis b. A blister like area c. An elevated hardened area. d. A cool, blanched area. Rationale: Page 136 of MEDSURG ATI BOOK. An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a positive skin test. 20. A nurse is caring for a client who has a chest tube drainage. Which of the following findings indicates the nurse the presence of an air leak? a. Gentle bubbling in the suction chamber b. Continuous bubbling in the water seal chamber c. Fluid rising with inspiration and falling with expiration in the water seal chamber d. D. Serosanguineous fluid in the drainage collection chamber. Rationale:ATI Med Surg book page 106. Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate the source of the air leak, and intervene accordingly (tighten the connection, replace drainage system). 21. A nurse is admitting a client to a med-surg unit. When performing medication reconciliation for the client. Which of the following actions should the nurse take? a. Compare new prescription with the list of medications the clients reports. b. Encourage the client to make his own list after he returns to his home. c. Exclude nutritional supplements from the list of medication the clients reports. d. Include any adverse effects of the medication the client might develop. 22. A nurse is caring for a toddler who has cancer and is experiencing stomatitis from chemotherapy. Which of the following intervention should nurse implement? a. Apply viscous lidocaine. b. Provide soft, nonacidic food c. Give peroxide mouth washes. d. Administer antiemetics 23. A nurse is teaching the family of an infant who has decreased cardiac output to congenital heart disease. Which of the following instruction should the nurse include in the teaching? a. Observe for manifestations of hunger in order to feed the infant before crying occurs keep crying to a minimum, crying increases workload of heart b. Bathe the infant and change the bed linens daily to reduce the risk of infection. c. maintain the infant in supine position when sleeping. d. Perform infant care activities frequently and intermittently throughout the day. 24. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? a. “Your child can return to school after a negative titer result.” b. “Your child can return to school 24 hours after beginning antibiotics.” c. “ Your child can return to school once the lesions have crusted over.” d. “Your child can return to school once the fever has subsided.” 25. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balanced suspension traction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearing aid d. A client who is ambulatory and receiving oxygen → RESCUE 26. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider? a. A client who is 4 hr postoperative and has a heart rate of 98/min b. A client who has a total of 110 mL of serosanguineous fluid from a Jackson- Pratt drain within the first 24 hr following surgery c. A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 d. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing 27. A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first? a. Encourage the family to assign specific tasks to individual family members. b. Determine the roles of individual family members. c. Assist the family to establish a daily routine d. Refer the family to a grief support group. Rationale: Assess first. 28. A nurse is planning to delegate tasks to an A P. Which of the following tasks should the nurse assign to the AP? a. Record the client's BP reading by 1000- documenting VS is RNS job b. Obtain a client temp prior to surgery- this CT is unstable since they are going to surgery c. Reposition a client- i didn't choose this because certain disease require clients to be in certain positions. d. Measure a client's urine output 29. A community health nurse is planning a program to address substance use in the adolescent population. Which of the following interventions should the nurse include as a method of secondary prevention? a. Facilitate referrals to substance use treatment programs (tertiary) b. Create anti-substance use media messages c. Establish an early detection program for substance use d. Provide education about the danger of substance abuse. (Primary) Rationale: Secondary preventions: Includes screening such as early detection. 30. A nurse in an ER is planning care for a client who has abdominal trauma from a MVC. Which of the following provider prescription should the nurse implement first? a. Administer RBC b. Place a large bore IV catheter in an upper extremity- IV FLUID REPLACEMENT IS PRIORITYAFTER ABCS c. Insert an indwelling urinary catheter d. Obtain a specimen for ABG analysis 31. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care? a. Weight loss of 5% in 10 days B. A ppearance of pink tissue under eschar c. H gb 15 g/dL d. A lbumin level 4.0 g/dL 32. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia which of the following is the nurse's priority? a. U rinary output 35 ml/hr- > 30 ml is normal b. 2 + deep tendon reflexes +2 is normal 3 or 4 is ABNORMAL d’t hyperreflexia. c. 3 + pedal edema d. Respiratory rate 10/min- normal rate 12 -20 ATI PHARM 33. A nurse is developing a plan of care for an older adult client who has hearing loss. Which of the following instructions the nurse include in the plan? A. Increase the pitch of voice when speaking to the client l ow pitch B. Avoid using hand motions when speaking to the client C. Rephrase statements that the client misunderstands D. Ask the client to confirm an understanding of the instructions by nodding. (I put this one -Jackie) 34 A nurse is collaborating with social services in the discharge planning for a young adult client who is below the poverty income level and will require home IV therapy. Which of the following resources the nurse recommend (SATA) A. Medicare Part A → must be 65 older (A; hospital care, home care, hospice, and skilled) B. Medicaid C. Adult day care D. Food stamps E. Respite care → Maybe? No. LOL. sorry paul. (yeah, no) Young Adult- 20-39 Medicaid → low socioeconomic status and children. 35. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? A. Overestimate clients acuity to prevent short staffing B. Obtain personal professional liability insurance coverage C. Ensure that each client has a living will on file prior to treatment. D.Place copies of incident reports in client's medical records. 36. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial Rationale ATI MS p309: Complications: Aspiration of gastric secretion Causes: Reflux of gastric fluids into the esophagus can be aspirated into the trachea. 37. A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use? A. Encourage collaboration between the two nurses when making the assignments B. Arrange for the nurses to have as few shifts together as possible C. Tell the nurses that the assignments will be more equitable in the future D. Ask each nurse to take turns making the assignments ATI Leadership 15 Open communication among staff & b/w staff and clients can help defray the need for conflict resolution. 38. A nurse is caring for a client who has received a first dose of losartan. Which of the following adverse effects should the nurse report to the provider immediately? A. Angioedema airway; A/E B. Cough C. Hypotension D. Itching Pharm 252 for HTN, HF. (Cozaar) 39. A nurse is caring for a client who has crohn’s disease. Which of the following should the nurse recommend for the client? A. Navy beans B. Bacon C. Banana D. Hard-boiled egg 40. A nurse is evaluating a client’s understanding of food nutrition labels. Which of the following statements by the client indicate an understanding of the teaching? a. The ingredient with the greatest weight appears first B. Food manufacturers provide nutrition information voluntarily c. Item serving size is consistent from one manufacturer to the next d. The daily values relate to a 1,500 calorie diet 2 ,000 http://www.mindfulbody.com/food/nutrition/nutritional-labels 41. A nurse is caring for a preschool-age child who has injuries due to a buse by her father’s partner. Which of the following actions by the nurse is a ppropriate? A. Limit visits by the father’s partner to 30 min B. Restruct the child’s interaction with other children on the unit C. Allow the father unlimited visitation with the child i assume father still has the right to see his child. He didn’t abuse him (I put this one -Jackie) D. Interview the child about the abuse with the father present. 42. A nurse is reviewing a client’s medical record. Which of the following findings places the client at increased for the development of heart failure? (SATA) A. Alcohol use disorder B. Osteoarthritis C. Sleep apnea D. Diabetes mellitus E. BMI 23 43. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Teach the client relaxation techniques B. B. Confirm the client’s perception of the event C. Help the client identify personal strengths. D. Notify the client’s support person. 44. A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective? A. Increased blood pressure- Loop diuretics decrease BP via making you PEE ALOt B. Decreased inflammation- loops are not pain meds they are for BP C. Weight loss- excretes excess fluids d/t HF D. Decreased pain - Loops are for BP 45. A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client? A. “How do you get along with your peers at school?” B. “Do you have thoughts of harming yourself” - safety is number 1 when it comes to priority C. “How do you manage your behavior?” D. “Do you have a criminal record?” 46. A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Ambulation four times daily B. Removal of vaginal packing C. Insertion of an indwelling urinary catheter so you will not have to get up and use the restroom D. Maintenance of NPO status until therapy is complete https://cancer.stonybrookmedicine.edu/diagnosis-treatment/radiation- oncology/info/brachytherapy 47. A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect? A. Stridor B. Pain on inhalation c hest pain that worsens when you breathe or pleuritic pain (I put this one -Jackie) C. Friction rub D. Bradycardia 48. A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse? A. Complete a discharge teaching for a client who has a new diagnosis of diabetes mellitus B. Perform a sterile dressing change for a client who has an abdominal wound C. Perform an admission assessment for a client who is scheduled for surgery D. Complete the Glasgow Coma Scale for a client who has an evolving stroke 49. A nurse is caring for a client who has bipolar disorder. Which of the following client findings is an indication that the client is about to experience a manic phase? A. The client is restless and has changes in his sleep pattern B. The client laughs out loud and is overly cheerful C. The client has disorganized thoughts and is easily distracted D. The client shows poor judgment and demands attention ( I put this one -Jackie) 50. A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures? A. Sheepskin heel pad B. Trochanter roll C. Abduction pillow D. Footboard p revents plantar flexion contractures due to immobility (I put this one -Jackie) 51. A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with an interpreter? A. Pause in the middle of sentences B. Use gestures when speaking with the client C. Direct statements to the interpreter D. Speak in a normal voice at a natural pace 52. A charge nurse is providing teaching to a newly licensed nurse about acceptable client identifiers before administering medications. Which of the following statements by the newly licensed nurse r equires intervention? A. “I will check the client’s hospital arm band before administering medication” B. “I will ask the client for his hospital assigned number prior to giving medication” C. “I should check the client’s room number prior to giving medication” D. “I should ask the client to state his name before administering medication” 53. A nurse is providing discharge teaching to a client who has hyperlipidemia and is to start treatment with atorvastatin. The nurse should instruct the client to avoid taking the medication with which of the following? A. Aged cheese B. Caffeinated beverages C. Green, leafy vegetables D. Grapefruit juice 54. A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor? A. Weight loss B. Bradycardia C. Bulging fontanel D. Distended jugular vein 55. A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? A. “Your child should avoid foods containing tyramine” B. “Your child should avoid excess sodium intake” C. “You should administer the medication at bedtime” D. “You should administer the medication after breakfast” a dminister med immediately during or after meals (I put this one -Jackie; it is a ADHD medication) 56. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for healthcare (DPAHC). Which of the following information should the charge nurse include? A. “The proxy can make financial decisions if the need arises” B. “The proxy should manage legal issues for the client” C. “The proxy should make healthcare decisions for the client regardless of the client’s ability to do so” D. “The proxy can make treatment decisions if the client is under anesthesia” 57. A nurse is admitting a client who has been taking p rednisone 10 mg PO daily for 10 months. Which of the following assessment findings should the nurse identify as an a dverse effect o f this medication therapy? A. Absence of hair on legs below the knees B. Swelling and decreased range of motion of the joints ( I put this one -Jackie) C. Thin extremities with obesity of the abdomen D. Bradycardia and postural hypotension 58. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has manifestations of e arly dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) A. Hypertension B. Diaphoresis C. Syncope D. Fever - idr putting this one E. Dizziness Early manifestations: Feeling of fullness, weakness, dizziness, palpitations, sweating, abdominal cramping, and diarrhea 59. A nurse is caring for a male client who has a s pinal cord injury. Which of hte following techniques should the nurse use when p roviding perineal care? A. Wash the penis from the scrotum to the tip using a spiral motion B. Discard the washcloth after cleansing the urethral meatus C. Don sterile gloves to prevent infection D. Use water with no soap to prevent skin irritation 60. A nurse is assessing a toddler whose parent is concerned about the child’s hearing ability. Which of the following findings indicates the need for further hearing evaluation? A. Lack of response to facial expressions B. Uses gestures to communicate C. Exaggerated startle response to sounds D. Prefers group over solitary play 61. A surgeon is obtaining informed consent from a client. When a nurse witnesses the client sign the consent form, which of the following legal requirements is the nurse confirming? a. The nurse explained the risks and benefits of the surgery- PROVIDERS JOB b. The nurse explained the surgical procedure in detail- PROVIDERS JOB c. The client knows she may not longer refuse the procedure- Client has the right to refuse even if its seconds prior to the surgery. d. The client agreed to the procedure voluntarily. - meaning she wasn’t forced to sign . 62. A nurse providing teaching about n utritional needs to an adolescent client. Which of the following statements by the client indicates an understanding of the teaching? a. I should consume about 1,300 milligrams of calcium a day b. Protein should be my main source of caloric intake c. I should limit my daily fat intake to 40 percent d. I should consume about 8 milligrams of iron a day 63. A nurse manager on an interprofessional team is creating a d isaster plan. T he nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? a. Determine the need for additional providers b. Act as a spokesperson to provider info to the media c. Decided which client should be transported for a higher level of care (I put this one -Jackie) d. Recommend to the provider a list of clients for early discharge 64. A nurse is caring for a client who is 2 hr postpartum. The client states, “ i'm having difficulty emptying my bladder.” which of the following actions should the nurse take? a. Pour warm water from a squeeze bottle over the client’s perineum b. Hold analgesic meds until the client voids c. Place a transcutaneous electrical nerve stimulation (TENS) unit over the client’s bladder area d. Immerse the client’s hands in cool water 65. A nurse is providing discharge teaching to a client who has c hronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? I dk the answer a. Eat 1g/kg of protein per day (I put this one -Jackie) b. Drink at least 3L of fluid daily ???? i picked this one but ima double check c. Consume foods high in potassium d. Take magnesium hydroxide for indigestion 66. A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P -R interval of 0.35sec. Which of the following dysrhythmia is the client displaying? a. Premature atrial complexes????????????? b. Complete heart block c. Atrial fibrillation d. First degree atrioventricular block (I put this one -Jackie) 67. A nurse is reviewing laboratory values for a client who has bipolar disorder and takes lithium carbonate. Which of the following values should the nurse report to the provider? a. Sodium 137 meq/L b. Lithium 1.0 meq/L? ????????????? c. WBC count 5,600 mm d. Thyroxine (t4) 2.8 mcg.dL (I put this one -Jackie) : l ithium can cause hypothyroidism and goiter, T4 normal range is 4.6-12 68. A nurse is planning teaching for a client who has a n ewly implanted implantable cardioverter/defibrillator. W hich of the following information should the nurse include? a. Return in two weeks for a follow up MRI - MRI should be avoided b. Expect to have a rapid pulse rate for the first few weeks ?? c. Resume tub baths and swimming after 24hr d. Wear loose fitting clothing (I put this one -Jackie) 69. A nurse is caring for a 2yr old toddler. Which of the following food choices should the nurse recommend to promote independence in eating? a. Grapes- choking hazrd b. Banana slices c. Hot dogs- choking haards d. Popcorn- choking hzard 70. A nurse is caring for a client who has a 22 gauge IV inserted 2 days ago and a new prescription for 2 packed RBCs. Which of the following actions should the nurse take? a. Transfuse each unit of packed RBCs over 5 hrs b. Replace the current IV site dressing prior to RBC infusion c. Start a new IV distal to the current IV site d. Place a larger gauge IV in the opposite extremity- RBC administration needs to have at least an 18 -20 bore gauge needle to administer. 71. A nurse is providing information for a client who has a new prescription for s imvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Fever b. Muscle weakness- statin drugs = RHABDOMYLOSIS c. Weight loss d. edema 72. A nurse is positioning a client for a cesarean birth. To p revent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? a. Place a w edge u nder one of the client’s hips b. Assist the client into the lithotomy position c. Position the client in reverse trendelenburg d. Insert a pillow under the client’s knees 73. A nurse is planning to delegate the f asting blood glucose testing for a client who has DM to an a ssistive personnel. Which of th following actions should the nurse take? a. Determine if the AP has the skills to perform the test b. Assign the AP to ask the client if she has taken her antidiabetic meds today c. Help the AP perform the blood glucose test d. Have the AP check the medical record for the prior blood glucose test results 74. A nurse is teaching an adolescent who has a type 1 diabetes mellitus and his parents h ow to dispose of his insulin syringes and needles at home. Which of the following instructions is a ppropriate? a. Seal the needles in zipper lock plastic bags and place them in a metal trash can b. Place the needles in a plastic container and then pour alcohol into the container c. Recap the needles and wrap them and the syringes in paper towels d. Place the needles in an aluminum coffee can and store them on a high shelf 75. A nurse is a long term care facility is caring for an older adult who has a d ementia. The client believes he needs to get ready for work and is becoming increasingly agitated. Which of the following actions should the nurse take? a. Assist the client in selecting clothing for the day b. Tell the client that his behavior is unacceptable c. Administer an anti anxiety medication d. Inform the client that he no longer has a job to go to 76. A nurse is assessing a young adult male client having an u nusual rash on the palms and hand and bottom of his feet. The nurse should further assess for which of the following infections? 1. Syphilis 2. Herpes simplex virus 2 3. Gonorrhea 4. Hepatitis B 77. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching ? 1. “Repeat the dose if your child vomits w/in 1 hr taking the medication” 2. “Have your child drink a small glass of water after swallowing the medication” I put this one -Jackie 3. “You can add the medication to a half cup of your child’s favorite juice” 4. “Limit your child’s potassium intake while she is taking this medication” 78. A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make? 1. When using implanted contraceptive methods, condoms should also be used to protect against STDs 2. Use of petroleum based lubricant with a condom increases the condom’s effectiveness 3. Ensure that the condom fits snugly over the tip of the penis 4. Condoms are equally effective for birth control with or without the use of vaginal spermicides 79. A nurse is assessing a client who is receiving a unit of packed RBCs. Which of the following findings should indicate to the nurse that the client is experiencing a h emolytic transaction reaction? 1. Bradycardia 2. Urticaria (hives) - allergic rxn (I put this one -Jackie) 3. Low blood pressure 4. Jugular vein distention - fluid overload Rationale: Hemolytic reactions: chills, headache, backache, dsypnea , hypotension, fever (KAPLAN) 80. A nurse is providing teaching to the parents of a newborn about n ewborn genetic screening. Which of the following statements should the nurse include in the teaching? 1. A nurse will draw blood from your baby’s inner elbow 2. This test should be performed after your baby is 24 hrs old 3. This test will be repeated when your baby is 2 months old 4. Your baby will be given 2 ounces of water to drink prior to the test 81. A nurse is evaluating the outcomes for a client who had an a mnioinfusion for o ligohydraminos. Which of the following findings indicates an a dverse response to this treatment? 1. Fetal cord compression 2. Placental insufficiency (OB p 102) - this CAUSES oligohydramnios, but the question is asking “adverse response” to amnioinfusion.. 3. Meconium aspiration 4. Uterine contractions - monitor the client to prevent uterine overdistention and increased uterine tone = can initiate/accelerate/intensify UTERINE CONTRACTIONS and cause nonreassurring FHR changes; (I put this one -Jackie) 82. A nurse has received clearance to go back to work after an occupational injury to her back. To r educe the risk of future lifting injuries, which of the following principles should the nurse use when lifting objects? 1. Bend at the waist to pick up the object 2. Keep the object close to her body as she lifts it 3. Twist at the waist when moving the object to her side 4. Stand with her feet close together when lifting the object 83. A nurse is teaching a client about a variety of s tress management techniques. Which of the following instructions by the nurse is a ppropriate? 1. Tighten your muscles before relaxing them when using muscle relaxation techniques 2. Breathe in through your mouth and out through your nose when using deep breathing exercises 3. Imagine a situation that has been stimulating for you when practicing guided imagery 4. Talk to someone who you admire as the first step in using mindfulness techniques to relax 84. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? 1. Release the tourniquet 2. Retract the stylet 3. Advance the catheter into the vein 4. Flush the catheter with saline 85. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? 1. Administer an antiemetic medication 2. Replace the NG tube 3. Provide functioning of the suction device 4. Evaluate function of the suction device 86. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an i ncident report? 1. A client requests his statin to be administered at 2100 2. A client asks for pain medication 1 hr early 3. A client vomits within 20mints of taking morning medications 4. A client receives his antibiotic 2 hrs late 87. A nurse is caring for a client who has prescriptions for furosemide and gentamicin. F or which of the following complications should the nurse monitor the client? P .143 pharm 1. Ototoxicity ??????????? i’m positive and sure it this one but ima double check 2. Liver toxicity (I put this one -Jackie) 3. Hyperkalemia 4. Hypoglycemia Always remember for those two meds - OTOTOXICITY i s always the complication 88. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? 1. Increased intracranial pressure 2. Upper extremity hypotension 3. Weak femoral pulses ( peds. P 112) 4. Frequent nosebleeds 89. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the following should the charge nurse identify as the purpose of telemetry monitoring? 1. To measure cardiac perfusion 2. To measure cardiac output 3. To identify dysrhythmias 4. To identify valve insufficiency 90. A nurse is caring for a client who is at 2 0 weeks of gestation and reports u rinary frequency. Which of the following actions is a ppropriate? 1. Advise the client to limit her evening fluid intake 2. Obtain a specimen for culture and sensitivity 3. Check the client for rupture membranes 4. Assure the client that this is an expected finding during this trimester (urinary frequency is common in pregnancy) - occurs during first and third trimester 106. A nurse is providing discharge teaching to a client who has undergone bowel surgery with placement of a colostomy. Which of the following information should the nurse include in the teaching? a. Eat a low-fiber diet if constipation occurs. b. Apply a skin sealant around the stoma before applying the pouch. (I put this one -Jackie) c. Make a pinhole in the pouch to allow for gasses to vent. d. Cut the opening of the wafer 2 cm (0.8in) wider than the stoma 108. A home health nurse is teaching the caregiver of a client who has AIDS about infection control in the home. Which of the following information the nurse include in the teaching? a. Dispose of recapped needles and syringes in biohazard bag. b. Wash clothing twice in cold water and laundry detergent. c. Designate a separate bathroom in the home for the clients use. d. Make a new solution of bleach and water each day for disinfection. 109. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Delegate tasks to the AP. b. Determine goals of the day (I put this one -Jackie) c. Schedule daily activities. d. Develop an hourly time frame for tasks. 110. A nurse is assessing a client who has antisocial personality disorder. Which of the following characteristics should the nurse expect? a. Exaggerated expression of emotion b. Sensitive to criticism c. Needs continues reassurance d. Lack of remorse (I put this one -Jackie) 111. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. Hgb 14 g/dL b. WBC count 2,900/mm (I put this one -Jackie) me too!! AGRANULOCYTOSIS c. Fasting blood glucose 100 mg/dL d. Heart rate 58/min 112. A nurse is performing a dietary assessment for a client. Which of the following questions should the nurse ask when assessing the client’s dietary acculturation? a. “Are there any foods that you are allergic to?” b. “How do you feel about your current body weight?” c. “What questions do you have about reading food labels?” d. “ Do you have special customs that you follow for meals?” (I put this one -Jackie) 113. A nurse is preparing to document care in a client’s electronic health record. Which of the following entries by the nurse demonstrates appropriate documentation? a. “Client drank orange juice at HS.” b. “Client has a heart rate of 102/min” (I put this one -Jackie) ME TOO I CHOSE THIS ONE c. “Client is demanding of nurse’s attention.” d. “Client appears nervous.” 114. A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (select all that apply) a. Addressing client needs when providing resources * b. Making decisions about health care on client’s behalf c. Promoting health care access* d. Encouraging clients to seek further information from the provider * e. Honoring family requests to withhold medical information *(I put this one -Jackie) 115. A nurse is providing teaching to a client about risk factors for breast cancer. Which of the following factors should the nurse include as placing the client at an increased risk for developing breast cancer? a. A BMI less than 25 b. Use of hormone replacement therapy (I put this one -Jackie) c. Early menopause d. Fibrocystic breast disease 116. A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? a. Schedule nursing staff training for infection control procedures b. Identify possible precipitating factors related to the infections (I put this one -Jackie) c. Meet with providers to discuss measure to decrease the infections d. Revise the current policy for catheter care 117. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate? a. “My throat feels tight.” (I put this one -Jackie)- THS ONE I CHOSE! THIS CAN BE ANAPYLACTIC RXN !!! b. “ I don’t understand why I am getting this antibiotic.” c. “My arms burn each time that medication is running.” d. “This medication bag is still full.” 118. A nurse is teaching a group of newly licensed nurses caring for a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? a. Apply a mask when providing care. b. Wear a gown while providing personal hygiene. (I put this one -Jackie) c. Place the client in a room with negative airflow. d. Wipe the stethoscope with alcohol after leaving the client's room. 119. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strips shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? a. Ventricular asystole b. Second-degree heart block c. Sinus Tachycard d. Atrial fibrillation (I put this one -Jackie) me too!!!!! A fib has no p waves and HIGH HEART RATE 120. A nurse is assessing a client who has type 1 diabetes mellitus and a blood glucose level of 52 mg/dL. Which of the following findings should the nurse expect? a. Deep respirations- this is KUSSMAUALS b. Hot, dry skin- HYPO is COOL and CLAMMY c. Bradycardia - HYPO is TACHY d. Blurred vision (I put this one -Jackie) me too!!!!!!! The rest is HYPERGYLCEMIA 121. A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? a. Placing the supplies on the sterile field and leaving a 1-inch perimeter b. Applying a sterile gown after applying a sterile mask c. Balancing the bottle on the sterile basin while pouring the liquid d. Putting on sterile gloves after preparing the sterile field 122. A nurse is preparing to administer several medications through a client’s nasointestinal tube. The nurse should ask the pharmacist about the availability of a different form for which of the following medications? a. Oral anticoagulant b. Statin tablet c. Antibiotic suspension d. Enteric-coated aspirin 123. A nurse is caring for a client who has a new prescription for clozapine. Which of the following should the nurse recognize as an adverse effect of this medication? a. Diarrhea b. Hypoglycemia c. Urinary frequency d. agranulocytosis 124. A nurse is planning care for a client who follows Buddhist dietary practices. Which of the following food selections should the nurse recommend for the client’s meal tray? a. Vegetable beef soup b. Spinach and strawberry salad c. Ham and cheese sandwhich d. Baked fish 125. A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients should the nurse plan to assess first? a. A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months b. A client who will be receiving her first ECT treatment today c. A client placed in restraints due to aggressive behavior d. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety 126. A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching? a. You can receive the immunization for influenza at any time during your pregnancy b. The immunization for varicella should be given at least 1 month prior to delivery c. The hepatitis B immunization should not be obtained until after you finish breastfeeding d. You can receive the rubella immunization during the third trimester of pregnancy 127. A public health nurse is teaching a group of new parents about SIDS. Which of the following statements by the parents indicates an understanding of the teaching a. “I will make sure the mattress in my baby’s crib is firm” <??? b. “My baby will no longer be at risk for SIDS when he reaches 6 months c. I can keep my newborn in bed with me at night to make bottle feeding easier d. I will avoid giving my baby a pacifier during naptimes 128. A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first? (Exhibit) Tab 1: H&P - 6 years old, vomited 3x in past 24h, irritable behavior for past 24h, respiratory infection started 3 days ago, Brudzinski’s and Kernig’s signs positive Tab 2: VS - RR 28/min, HR 120/min, BP 108/64, pain 6/10 Tab 3: Meds - vancomycin 300 mg IV q6h following blood cultures, Acetaminophen 240 mg PO 6hr PRN fever a. Initiate seizure precautions<<<menigitis b. Collect blood cultures c. Transport the child to obtain a CT scan d. Obtain a prescription for pain medication 129. A nurse in the ED is caring for an adolescent who has acute appendicitis and reports pain at McBurney’s point. The nurse should identify which of the following areas as McBurney’s point? 130. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Give the client protamine if the signs of magnesium sulfate toxicity occur b. Monitor the FHR via doppler q30 min c. Restrict the client’s total fluid intake to 250 mL/hr d. Measure the client’s urine output qh- i chose this one becasue you want output to be 30 ml per hour at the least . anything less than that means that they are retaiing the MAG SULFATE 131. A nurse is providing teaching to a client about the adverse effects of Sertraline. Which of the following adverse effects should the nurse include? a. Excessive sweating - serotonin syndrome = ch 8 p 53 pharm b. Metallic taste in mouth c. Increased urinary frequency d. Dry cough 132. A nurse is caring for a client who has tuberculosis. The client tells the nurse he has not been taking his medication because he can no longer afford to purchase it. Which of the following statements should the nurse make? a. I will ask the social worker to come speak with you about this situation b. I will tell your provider that you do not want take the medication c. You should budget your money to be able to purchase this medication d. You should ask your family to purchase the medication for you 133. A nurse in an ED is caring for a client who is having manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take? P . 84 ch 15 a. Place the client in high-fowler’s position b. Prepare the client for a chest x-ray c. Initiate fibrinolytic therapy- you got a window of 6 hours! Its contraindciates for HEMORRHAGIC STORKE d. Insert an indwelling urinary catheter 134. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? a. Food label recommendations from the institute of medicine b. Personal blogs about managing the adverse effects of diabetes medications c. Food exchange lists for meal planning from the american diabetes association d. Diabetes medication information from the physicians’ desk reference 135. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first a. A client who has hyporeflexia while receiving magnesium sulfate b. A client who reports abdominal pain during breastfeeding- normal, since youtr stimulating oxytocin c. A client who reports changing her perineal pad every 2 hr… q 15 minutes would be a problem d. A client who has a UO of 250 mL in 6hr= 30 x 6 = 180 136. A nurse is preparing to administer methylprednisone sodium succinate to a client who has chronic inflammatory disorder. The nurse should plan to monitor which of the following laboratory tests while the client is taking this medication? a. INR b. PaO2 c. Troponin T d. Serum glucose (I put this one -Jackie) 137. A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated for this medication? a. Eggs b. Cheese (I put this one -Jackie) c. Grapefruit d. Potatoes 138. A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac disease. Into which of the following positions should the nurse place the client to best promote optimal cardiac output? a. High-Fowler’s b. Left-lateral (I put this one -Jackie) c. Supine d. Standing 139. A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider? a. The client states, “Being in the sun seems to really hurt my eyes.” b. The client is observed displaying a shuffling gait while walking in the hall. c. The client is observed mumbling quietly while alone in the day room. d. The client states, “I feel light-headed when i stand up quickly.” 140. A nurse is reviewing laboratory findings for a client who is to receive a dose of enoxaparin. For which of the following laboratory values should the nurse withhold the dose and notify the provider? a. WBC 15,000/mm3 b. Urine specific gravity 1.035 c. Platelets 80,000/mm3- GIVEN d. BUN 25 mg/dL 141. A nurse manager is confronted by a staff nurse who complains that her assignment is unfair. Which of the following responses should the nurse manager make? a. “You are being unreasonable about your assignment.” b. “You seem to be upset about your assignment.” c. “I will always try to be fair when i make assignments.” d. “I can't believe you think this assignment is unfair.” 142. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following indicates that the child maybe experiencing hemmorrhage? a. Diminished breath sounds b. Elevated pain level c. Frequent swallowing- they can indicate bleeding. d. Increased drowsiness 143. A nurse is caring for a client who states that the first day of her last menstrual cycle was June 14. Using Nagele’s rule, the nurse should calculate the client’s estimated date of delivery as which of the following? a. April 14 b. March 21 - 3 months and + 7 months c. March 14 d. February 14 144. A nurse on a medical-surgical unit is receiving report for four client. Which of the following clients should the nurse assess first? a. A client who is scheduled for chemotherapy and has an RBC count of 4 million/mm3 b. A client who is 24hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing c. A client who is receiving a blood transfusion and reports low-back pain d. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag 145. A nurse is admitting a client who has dementia to a long-term facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings? a. Confabulation b. Perseveration c. Agnosia d. Projection 146. A nurse is completing an admission assessment for a client who is scheduled for surgery. Which of the following client allergies should the nurse report to the provider? a. Eggs b. Peanuts c. Wheat d. Shellfish 147. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse but the new bag is not readily available. Which of the following actions should the nurse take? a. Administer dextrose 10% in water b. Slow the infusion rate c. Temporarily discontinue the infusion d. Give 500 mL of lactated Ringer’s solution 148. A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take? a. Report the infection to the state department of health b. Schedule the client for retesting in 1 week c. Administer ceftriaxone via intermittent IV bolus d. Instruct the client to abstain from abstain from sexual intercorse for 1 month 149. A nurse is providing discharge teaching to the provider who has a tracheostomy. Which of the following information should the nurse include in the teaching? a. How to change the tracheostomy dressing using clean technique b. How to operate the portable suction machine c. How to change the non disposable tracheostomy tube daily d. How to secure the tracheostomy tube with ties at the back of the neck 150. A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively? a. Complete partial assessments on all clients before planning the day b. Prioritize activities based on the nurse's needs c. Use the break time to perform documentation d. Gather supplies prior to completing a dressing change 151. A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? a. “I can store the medication in the refrigerator.” b. “I should keep the medication in the original container.” c. “I can crush the medication and mix with applesauce.” d. “I should replace any unused medication every 6 months.” 152. A nurse is providing discharge instructions to a client who is 1-day postoperative following a vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding of the dietary teaching? a. “I will be limited to pureed foods for the next 6 months.” b. “I should eat three meals per day.” c. “It should take me 30 to 60 minutes to eat a meal.” d. “Vomiting is common ant I will have to learn to live with it.” 153. A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client’s intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care? a. Keep the client in a supine position b. Maintain ICP at 20mm Hg c. Suction the client every 2 hr d. Avoid overstimulation of the client 154. A nurse is planning care for a child who has neutropenia die to leukemia. Which of the following interventions should the nurse include in the plan of care? a. Prepare the child for a platelet transfusion b. Initiate a low-protein diet for the child c. Screen the child’s visitors for active infections d. Monitor the child for indications of active bleeding 155. A nurse is caring for an older adult client who has hemiparesis following a stroke. Which of the following actions should the nurse take to prevent falls? (SATA) a. Leave the client’s bathroom light on b. Have the client wear shoes while ambulating to the bathroom c. PLace a nonskid mat on the shower floor d. Place the client’s bedside table at the foot of the bed e. Keep the client’s bed in the lowest position 156. A nurse is providing prenatal teaching for a client who has herpes simplex virus. Which of the following client statements indicates an understanding of the teaching? a. “I won’t pass herpes on to my baby if I’ve only had an outbreak for a week” b. “I can’t take acyclovir during pregnancy because it might hurt my baby.” c. “My herpes infection has to be reported to the Centers for Disease Control and Prevention.” d. “I should have a cesarean delivery if I’m having an outbreak.” 157. A nurse receiving change-of-shift report from the nurse on the previous shift. Which of the following information should the nurse include in the report? a. “Client in room 302 has visitors.” b. “Client in room 303 needs his 8am blood glucose before his scheduled insulin.” c. “Client in room 301 is in the cardiac catheterization lab.” d. “Client in room 304 is doing poorly.” 158. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist? a. The client’s parent is in a skilled nursing facility b. The client is allergic to penicillin c. The client has two small children at home d. The client lives in a two-story home - i picked this one, OT’s help out with ADL’s, maybe hell have a haard time walking up stairs or carrying himself or objects up stairs. 159. A nurse is obtaining a blood specimen from a client who has a peripherally inserted central catheter. Which of the following actions should the nurse take? a. Use a 3mL syringe to flush the catheter b. Instruct the client to perform the Valsalva maneuver during the blood draw c. Cleanse the port with povidone-iodine prior to obtaining the specimen d. Flush with 20mL of 0.9% sodium chloride after obtaining the blood sample 160. A nurse is providing dietary teaching to a client who has heart failure. Which of the following recommendations is appropriate for this client? a. Encourage seasoning with dry herbs b. Increase fluids to 2L/day c. Use saturated oils when cooking d. Increase consumption of dairy products 161. A Nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Maintain eye contact with the newborn during feedings b. Minimize noise in the newborn’s environment c. Administer naloxone to the newborn. d. Swaddle the newborn with his legs extended 162. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? a.” b. “I family should help make his health care decisions.” will inform a client that his c. “I will intervene if there is a conflict between a client and his provider.” d. “I should not advocate for a client unless he is able to ask me himself.” 163. A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP? a. Performing postmortem care b. Explaining the steps for a 24-hr urine collection c. Assisting with low-carbohydrate diet selections d. Interpreting blood glucose values 164. A nurse is planning discharge care for an older adult client who tells the nurse he does not like living alone because he is afraid of falling. Which of the following resources should the nurse assist the client to explore prior to discharge? a. Ambulatory care center b. Assisted living center c. Skilled nursing facility d. Hospice care 165. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening? a. Observe for sacral dimpling b. Observe for a positive Romberg sign c. Measure the anteroposterior diameter of the chest d. Measure the truncal rotation 166. A nurse is providing discharge teaching about oxycodone to a client who had an appendectomy. Which of the following information should the nurse include in the teaching? a. Decrease fiber intake while taking his medication to prevent diarrhea. b. Urinary frequency is an adverse effect of this medication. c. Slow respirations can occur when taking this medication. d. Pain relief should occur 5 min after taking this medication. 167. A nurse is preparing information about skin care for a client who has cancer of the prostate and is receiving radiation therapy. Which of the following information should the nurse include? a. Clean the perineal area using a washcloth. b. Dry the perineal area by using a patting motion c. Apply heat packs to the affected area as needed d. Wear snug-fitting underwear 168. A nurse is providing preoperative teaching to an older adult female client who is scheduled for a laminectomy and uses supplements. Which of the following supplements should the nurse identify as increasing the client’s risk for hypotension during surgery? a. Soy b. Flaxseed c. Probiotics d. Black cohosh 169. A nurse is assessing a client who is preoperative for abdominal surgery. Which of the following findings should the nurse identify as the priority? a. WBC 11,000/mm3 b. Temperature 38.1 C (100.5 F) c. Potassium 3.4 mEq/L d. Heart Rate 130/min 170. A nurse is teaching a group of parents about expected development of gross motor skills during infancy, The nurse should teach that the following developmental tasks are expected to occur in what order? - Rolls from back to side 1 - Rolls from back to abdomen 2 - Changes from prone to sitting 3 - Sits steadily unsupported. 4 171. A nurse is planning care for a client who has stage II Parkinson’s Disease. Which of the following actions should the nurse include in the plan of care? a. Offer clear liquids with and between meals b. Offer high-calorie nutrition supplements c. Encourage the client to concentrate on looking at his feet while walking. d. Encourage the client to participate in small muscle dexterity activities. 172. A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider? a. Frequent nausea b. Breast tenderness c. Weight Gain 2.3kg (5lb) d. Persistent Headache 173. A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first ? (click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Encourage the client to verbalize feelings. b. Implement seizure precautions for the client. c. Administer ondansetron to the client for nausea. d. Obtain the client’s weight. 174. A nurse is planning care for a client who is receiving internal radiation therapy to treat uterine cancer. Which of the following interventions should the nurse include in the plan? a. Tell visitors to remain at least 1.8 m(6 feet) away from the client. b. Place the client in a semi-private room with a roommate who is noninfectious. c. Instruct the client that she can ambulate to the bathroom. d. Allow children younger than 16 years of age to visit for up to 1 hr per day. 175. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching? a. Round the edges of toenails when trimming. b. Use moisturizing lotion between the toes c. Wear clean cotton socks every day. d. Soak feet twice daily. 176. A nurse is preparing to administer cefpodoxime 10 mg/kg/day PO divided equally every 12 hr to a child who weighs 66. Available is cefpodoxime 20 mg/ml oral solution. How many ml should the nurse administer per dose? (Round the answer to the nearest tenth. Usea leading zero if applicable. Do not use a trailing zero.) 66 lbs. /2.2= 30 kg 30kg x 10 mg=300 mg/day 300 mg/2 doses= 150 mg/dose 150 mg/20mg x 1ml= 7 .5 ml/dose 177. A nurse on a medical-surgical unit is planning care for a group of clients. Which of the following clients should the nurse plan to see first? a. A client who has diabetes mellitus and a morning blood glucose level of 120 mg/dL. b. A client who has heart failure and an oxygen saturation level of 89% c. A client who has atrial fibrillation and a ventricular heart rate of 105/min d. A client who has polycystic kidney disease and a blood pressure of 130/85 mmHg 178. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure prior to meals b. Administer a bronchodilator after the procedure c. Hold hand flat to perform percussions on the child. d. Perform the procedure twice a day. 179. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications a. Contractions b. Hypertension c. Vomiting d. Epigastric pain 180. A nurse is providing care for a group of clients. Which of the following client’s should the nurse assess first? a. A client who has pneumonia with a productive cough b. A client who has a NG tube in place and reports nausea c. A client who received an opioid for pain following an appendectomy and has an SaO2 of 94% d. A client who has a fracture tibia and reports shortness of breath 180. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state? a. “How long have you been hearing the voices?” b. “What are the voices telling you?” c. “Have you taken your medication today?” “I realize the voices are real to you, but I don’t hear anything.”- 1. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco decreases level of athletic ability b. Smoking in adolescence increases the risk of lifelong addiction c. Smoking in adolescence increase the risk of developing lung cancer later in life d. Use of tobacco might lead to alcohol and drug abuse 2. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? a. Make quarantine preparations for those exposed to anthrax b. Vaccinate susceptible children and adults against smallpox c. Participate in community drills and mock events d. Asses types, levels, and scopes of disasters 3. A nurse is obtaining a nutritional health history on a client who reports problems with constipation. Which of the following findings should the nurse identify as a cause of constipation? a. Intolerance to lactose b. New prescription for an iron supplement c. Following a high-fiber diet d. Currently taking probiotics 4. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expecting finding? a. Frequent nosebleeds b. Upper extremity hypotension c. Increased intracranial pressure d. Weak femoral pulses 5. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is the therapeutic? a. Can you talk about what was happening with you partner at home? b. Why do you think your partner’s symptoms are progressing so quickly? c. You should make sure your partner takes the prescribed medication d. You did the right thing by bringing your partner in for treatment 6. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take? a. Close all nearby windows and doors (3) b. Transport the client to another area of the nursing unit (1) c. Use the unit’s fire extinguisher to attempt to put out the fire (4) d. Activate the facility’s fire alarm system (2) 7. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take? a. Perform a vaginal examination b. Initiate an amnioinfusion c. Continue to monitor the fetal heart rate d. Stop the oxytocin infusion 8. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. Your baby will be given 2 oz of water to drink prior to the test b. This test should be performed after your baby is 24 hr old c. A nurse will draw blood from your baby’s inner elbow d. This test will be repeated when your baby is 2 months old 9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Previous violent behavior b. A history of being in prison c. Experiencing delusions d. Male gender 10. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. This type of seizure can be mistaken for daydreaming b. The child usually has an aura prior to onset c. This type of seizure has a gradual onset d. This type of seizure lasts 30 to 60 seconds 11. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% b. A client who has sinus arrhythmia and is receiving cardiac monitoring c. A client who has a hip replacement and anew onset of tachypnea d. A client who has epidural analgesia and weakness in the lower extremities 12. A nurse in a prenatal clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. A transcutaneous electrical nerve stimulator will help with pelvic pressure b. I can use my ultrasound picture as a focal point during contractions c. The nurse will initiate acupuncture when I arrive at the unit d. My nurse can teach me biofeedback at the beginning of labor 13. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. I will receive a small fee for interpreting for this client b. I will let the client know that I am available as the interpreter c. I am glad I am available today, but when I’m not, you can use a family member d. I will let the client know that an interpreter is unavailable during the night shift 14. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Insert an indwelling urinary catheter b. Pour water from a squeeze bottle over the client’s perineal area c. Perform fundal massage d. Apply cold therapy to the client’s perineal area 15. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s laboratory findings reveal a potassium level of 5.5 mEq/L, a BUN of 15 mg/dL, and a creatinine level of 1 mg/dl. Which of the following interventions is appropriate for the nurse to take? a. Initiate a 24 hr urine collection b. Administer oral potassium to the client c. Place a cardiac monitor on the client d. Stop the IV infusion of insulin 16. A nurse is caring for a client who has COD and is 5 kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Request non-gas-forming foods from the dietary department b. Limit the client’s food consumption between meals c. Arrange for a low protein diet d. Administer a bronchodilator following meals 17. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Fibrocystic breast condition b. Asthma c. Fibromyalgia d. Hypertension 18. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? a. 3+ deep-tendon reflexes b. Protruding hemorrhoids c. Supine hypotension d. Urinary frequency 19. A nurse is caring for a client who is insulin dependent and is undergoing test to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? a. Fasting blood glucose 60 mg/dl b. HbA1c 6.5% c. Postprandial blood glucose 190 mg/dl d. Hct 42% 20. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? a. Identify solutions prior to negotiation b. Focus on how the conflict occurred c. Attempt to understand both sides of the issue d. Personalize the conflict 21. A nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful behavior b. Suspicious demeanor c. Seductive behavior d. Lack of remorse 22. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine form the bladder is restored? a. Fundus firm and to the right of the abdominal midline b. Two voids of 150 ml each over the past 2 hr c. Uterine atony d. Fundus 2 fingerbreadths above the umbilicus 23. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct health care professionals to identify abusive situations b. Connect abuse survivors with legal counsel c. Teach parenting skills to families at risk for abuse d. Locate financial support to open a shelter for abuse survivors 24. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. Let’s talk about how you can change your response to stress b. We should establish our roles in the initial session c. Let me show you simple relaxation exercises to manage stress d. We should discuss resources to implement in your daily life 25. A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. Add medication directly to enteral feeding b. Dissolve the medication together c. Use a syringe to allow the medications to flow by gravity d. Flush the NG tube with 5 ml water 26. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? a. Metallic taste in mouth b. Increased urinary frequency c. Excessive sweating d. Dry cough 27. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect? a. Hypotension b. Memory loss c. Slurred speech d. Elevated temperature 28. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. I will decrease my daily protein intake to 15 grams per day b. I will use ibuprofen as needed to control abdominal pain c. I will take sucralfate with meals three times per day d. I will avoid food and beverages that contain caffeine 29. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Refer the client to a meal delivery program b. Arrange for client transportation to follow-up appointments c. Identify environmental hazards in the home d. Educate the client about current medical diagnose 30. A nurse is assessing a client who is inactive labor. Which of the following findings should the nurse report to the provider? a. Contractions lasting 80 seconds b. Early decelerations in the FHR c. FHR baseline 170/min d. Temperature 37.4 C (99.3 F) 31. A nurse is caring for a child who has sickle cell anemia and is experiencing vaso-occlusive crisis. Which of the following actions should the nurse include in the plan of care? a. Initiate IV fluid replacement b. Encourage ambulation c. Give aspirin to reduce pain d. Start a 24 hr urine collection 32. A nurse is assessing a client who has heart failure and is taking furosemide. For which of the following findings should the nurse monitor? a. Hypercalcemia b. Hyperkalemia c. Hypoglycemi a d. Hyponatremia 33. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to assistive personnel? a. Apply a transdermal nicotine patch b. Assess effectiveness of antiemetic medication c. Perform chest compressions during cardiac resuscitation d. Perform a dressing change for a new amputee 34. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrives. Which of the following statements by the nurse is appropriate? a. Teach your son to change the baby’s diapers b. Offer your son a gift when the baby receives one c. Tell your son to kiss the baby d. Move your son to a toddler bed when the baby arrives 35. A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? a. Fetal anemia b. Maternal hypoglycemia c. Maternal fever d. Chorioamnionitis 36. A nurse is caring for a client who has pernicious anemia. Which of the following laboratory values should the nurse monitor to evaluate effectiveness of the treatment? a. Creatinine level b. INR level c. Vitamin B12 level d. Folate level 37. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Take magnesium hydroxide for indigestion b. Eat 1 g/kg of protein per day c. Consume foods high in potassium d. Drink at least 3 L of fluid daily 38. A charge nurse is providing teaching to a group of newly licensed nurses about the grieving process. Which of the following information should the charge nurse include in the teaching? a. Clients can expect to have feelings of hopelessness b. Clients will experience anhedonia c. Clients will experience low self esteem d. Clients might feel guilty over some aspects of their loss 39. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. White, diffuse peritonsillar pustules b. Scratchy, high-pitched sound upon S-T segment c. ECG demonstrates a depressed S-T segment d. Report of occipital headache 40. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? a. Establish a toileting schedule for the client b. Use the clothing with buttons and zippers c. Discourage physical activity during the day d. Engage the client in activities that increase sensory stimulation 41. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Apply the patch within 1 hr of removing it from the protective pouch b. Wear gloves to apply the patch to the client’s skin c. Shave hairy areas of skin prior to application d. Remove the previous patch and place it in a tissue 42. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. I should cut my pouch opening 1/8 inch larger than my stoma b. I should clean my stoma with warm water c. I should change the stoma pouch every day d. My stoma should be bright pink or red 43. A nurse is assessing a client following an ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? a. The client has poor-fitting dentures b. The client reports a metallic taste in his mouth c. The client reports a decreased appetite d. The client coughs after swallowing 44. A client’s partner tells a staff nurse that he overhead laboratory staff discussing the results of the client’s biopsy report while on the elevator. Which of the following actions should the nurse take? a. Notify the facility’s legal department b. Review confidentiality policies with laboratory employees c. Contact the laboratory manager regarding the situation d. Report the information to the charge nurse 45. A nurse is assessing a client who request an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infection d. Migraines with aura 46. A nurse us caring for a school-age-child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take? a. Apply continuous pressure 2.5 cm (1in) above the percutaneous skin site b. Apply intermittent pressure 2.5 cm (1in) below the percutaneous skin site c. Apply continuous pressure 2.5 cm (1in) below the percutaneous skin site d. Apply intermittent pressure 2.5 cm (1in) above the percutaneous skin site 47. A nurse is caring for a client who has a major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Hypertension b. Urinary retention c. Weight loss d. Increased salivation 48. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? a. Moving both crutches with stronger leg forward first b. Positioning both hands on the grips with his elbows slightly flexed c. Supporting his body weight while leaning on the axillary crutch pads d. Stepping with his affected leg first when going up stairs 49. A nurse is preparing a change -of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? a. Potassium 4.2 mEq/L b. RBC 4.4 million/mm³ c. Platelets 100,000/mm³ d. Hgb 12.8 g/dl 50. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Encourage rural residents to focus health spending on tertiary health interventions b. Have a nurse from outside the community provide health lectures at the county hospital c. Launch a media campaign to increase awareness about industrial pollution d. Provide anticipatory guidance classes to parents through public school 51. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? a. Numbness and tingling of the extremities b. Headache c. Sensation of skin warmth d. Increased salivation 52. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A residual of 65 mL 1 hr postprandial b. Sitting in a high-fowler’s position during the feeding c. A history of gastroesophageal reflux disease d. Receiving a high osmolarity formula 53. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Fasting blood glucose 103 mg/dL b. BUN 16 mg/dL c. Potassium 3.2 mEq/L d. PT 12.2 seconds 54. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. Fasting blood glucose 100 mg/dL b. Heart rate 58/min c. WBC count 2,900/mm³ d. Hgb 14 g/dL 55. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? a. Decreased hematocrit b. Orthostatic hypotension c. Neck vein distention d. Dependent edema 56. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? a. Monitor the dorsalis pedis pulse every 15 min b. Keep the client NPO for 24 hr c. Place the client in Fowler’s position d. Maintain strict bedrest for the first 12 hr 57. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first? a. Instruct the client about the steps of the procedure b. Document the sequence of events as they occur c. Provide nonpharmacological pain management interventions d. Inform the provider of the time of the last dose of pain medication 58. A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Check the client’s motor strength b. Test the client for Trousseau’s sign c. Measure the client’s pupil size d. Assess the client’s skin turgor 59. A nurse is caring for a client who report xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Instruct the client on the use of esophageal speech b. Suggest rinsing his mouth with an alcohol-based mouth wash c. Offer the client saltine crackers between meals d. Provide humidification of the room air 60. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. The provider will be tactful when talking to your partner b. Is there a reason you don’t want your partner to know about your procedure? c. You have the right to decide who receives information d. Your partner can be a great source of support for you at this time 61. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? a. Encourage the client to take frequent rest periods b. Encourage the client to spend time in the day room c. Place the client in seclusion when he exhibits signs of anxiety d. Withdraw the client’s TV privileges if he does not attend group therapy 62. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? a. I should take antibiotics when I have the virus b. I can visit my nephew who has chickenpox 5 days after the sores have crusted c. I can clean my cat’s litter box during my pregnancy d. I should wash my hands for 10 seconds with hot water after working in the garden 63. A nurse is admitting an older adult client who is transferring form another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? a. Privately interview the client about her condition b. Notify risk management c. Contact the family regarding the client’s condition d. Inform the transferring agency of the client’s condition 64. A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). the nurse should identify the weight loss as which of the following total percentages? a. 13.3% b. 7.5% c. 8.1% d. 15% 65. A nurse is assessing a client’s respirations. Which of the following actions should the nurse take? a. Count respirations for 1 min if the rhythm is irregular b. Multiply the number of respirations in 15 seconds by 4 c. Inform the client that his breaths will be counted d. Assess respirations before counting radial pulsations 66. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. The nurse will ask you to wear protective eyewear during this procedure b. You should not have this procedure if you are allergic to iodine c. The nurse will ask you to remove any transdermal patches prior to the procedure d. You should not have this procedure if you have a tattoo 67. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy? a. Peripheral neuropathy b. Osteoarthritis c. Abdominal aortic aneurysm d. Phlebitis 68. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Renal insufficiency b. Seizure disorder c. Gluten intolerance d. Polycystic ovary syndrome 69. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following should the nurse expect? a. Bounding pulse b. Hypoglycemia c. Board-like abdomen d. Increased PaO2 70. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizure and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is having adverse effects due to combination antimicrobial therapy b. The client is showing evidence of phenytoin toxicity c. The client is experiencing an adverse reaction to rifampin d. The client’s seizure disorder is no longer under control 71. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Perform exercise prior bedtime b. Eat a light snack before bedtime c. Stay in bed at least 1 hr if unable to fall asleep d. Take a 1 hr nap during the day 72. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Complete oral hygiene b. Take pancrelipase c. Use an albuterol inhaler d. Eat a meal 73. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below-the-knee amputation b. Fracture tibia c. 95% full-thickness body burn d. 10 cm (4 in) laceration to the forearm 74. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Perform range-of-motion exercise to the client’s extremities b. Place the client’s right hand in a supination position c. Change the client’s position every 2 hr d. Maintain NPO status for the client 75. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. I try to respond to the baby quickly so she doesn’t cry very long b. I want to meet other parents to see if they are going through the same thing c. I have several friends who come by to help out with the baby d. I think the baby should be sleeping through the night by now 76. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 ml of urine b. Don sterile gloves prior to the procedure c. Obtain a 12 French catheter d. Apply EMLA cream prior to the procedure 77. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 b. A client who has preeclampsia and reports a persistent headache c. A client who has pregestational diabetes mellitus and an HbA1c of 6.2 % d. A client who is at 28 weeks of gestation and reports leukorrhea 78. A nurse is assessing a client’s telemetry strip. Which of the following findings should the nurse report to the provider? a. S-T segment elevations b. Widened P wave c. Heart rate 98/min d. 2 PVCs/min 79. A nurse in an emergency department is caring for a client who has a full thickness burn of the thorax and upper torso. After securing the client’s airway, which of the following is the nurse’s priority intervention? a. Initiating IV fluid resuscitation b. Providing pain management c. Preventing infection d. Offering emotional support 80. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks b. I can resume activities, such as sewing c. I can lift objects that are less than 10 pounds d. I should bend at the waist when putting on my shoes 81. A nurse is caring for a client who has lung cancer and has sealed radiation implant. Which of the following actions should the nurse take? (select all that apply) a. Limit visitors to 30 min per day b. Close the door to the client’s room c. Place the client in a semi-private room d. Wear a lead apron when providing care e. Instruct visitors who are pregnant to remain 3 feet from the client 82. A nurse is reviewing the medical record of a client. The nurse should identify that the client I at risk for which of the following complications? (Exhibit question) a. Hepatotoxicity b. Ketoacidosis c. Dumping syndrome d. Thyroid storm 83. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client. The client’s partner and 10-years old are accompanying her. Which of the following actions should the nurse take to gather the client’s admission data? a. Have the client’s child translate b. Ask a nursing student who speaks the same language as the client to translate c. Request a female interpreter through the facility d. Allow the client’s partner to translate 84. A community health nurse is teaching a client who has type 1 diabetes mellitus and is at 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. I will decrease my calorie consumption during the first trimester b. I will need to increase my insulin doses later in my pregnancy c. I will decrease my protein intake during the third trimester d. I will increase my carbohydrates at breakfast and limit them the rest of the day 85. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority? a. Xerostomia b. Client reports a pain level of 6 on a scale from 0 to 10 c. Excoriation of the skin on the neck and chest d. Dysphagia 86. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client has a history of asthma b. The client takes furosemide twice daily c. The client has a history of alcohol use disorder d. The client takes vitamin C daily 87. A nurse has jut received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who is scheduled for a procedure in 1 hr b. A client who was just given a glass of orange juice for a low blood glucose level c. A client who received a pain medication 30 min ago for postoperative pain d. A client who has 100 mL of fluid remaining in his IV bag 88. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Administering potassium via IV bolus b. Documenting communication with a provider in the progress notes of the client’s medical record c. Leaving a nasogastric tube clamped after administering oral medication d. Placing a yellow bracelet on a client who is at risk for falls 89. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed after your baby develops his antibodies b. You must use a nipple shield when breastfeeding c. You must use a breast pump to provide breast milk d. You may breastfeed unless your nipples are cracked or bleeding 90. A case manager is meeting with a client who ask about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? a. We can review some information to help you select a safe alternative practitioner b. Feel free to try whatever therapies that fit within your personal belief system c. I’m sure you can find alternative remedies through an online support group d. If there are therapies available to you, your provider will tell you about them. 91. A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will apply topical lidocaine following each diaper change b. I will apply an ice pack to my baby’s penis twice daily to increase swelling c. I will change my baby’s diaper at least every 4 hours d. I will wash the penis with soap and warm water until the circumcision has healed 92. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? a. HbA1c level less than 7% b. HbA1c level greater than 8% c. Blood glucose level less than 60 mg/dL before breakfast d. Blood glucose level greater than 200mmg/dL at bedtime 93. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? a. A client who is taking warfarin and has an INR of 1.8 b. A client who is schedule for a colonoscopy and is taking sodium phosphate c. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L d. A client who received a Mantoux test 48 hr ago and has an induration 94. A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Schedules a bag and tubing change for 24 hr after the start of the infusion b. Gradually increases the TPN infusion rate each hr until the prescribed rate is achieved c. Plans for a check of the client’s fingerstick glucose level every 6 hr d. Uses the TPN IV tubing to administer the client’s next dose of antibiotics 95. A nurse is collecting a specimen for urinalysis and culture form a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Obtain the urinalysis specimen before the culture specimen b. Collect 2 ml of urine for each specimen c. Clamp the catheter distal to the injection port d. Drain the specimen form the drainage bag 96. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first? a. Calculate fluid replacement based on vital signs and urinary output b. Determine the location and depth of the burns c. Check the mouth for soot and smoky breath d. Administer antibiotics prophylactically to prevent sepsis 97. A nurse is admitting a client who has acute heart failure. Which of the following prescriptions should the nurse anticipate? a. Ambulate the client every 4 hr while awake b. Administer enalapril 2.5 mg PO twice daily c. Provide the client with a 4 g sodium diet d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr 98. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state department? a. Chlamydia b. Human papillomavirus c. Candidiasis d. Herpes simplex virus 99. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. Can you list your current medications? b. Can you tell me who visited you today? c. What high school did you graduate from? d. What did you have for breakfast yesterday? 100. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an increase in which of the following laboratory values? a. Serum potassium level b. Serum calcium level c. Serum glucose level d. Lymphocyte count 101. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Bruising to the face b. Increase in frequency of swallowing c. Moderate sanguineous drainage on the drip pad d. Absent gag reflex 102. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Sweeten foods with fructose corn syrup c. Increase intake of milk products d. Consume food high in bran fiber 103. Exhibit Question 104. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? a. Administer the blood via a 21-gauge IV needle b. Set the IV infusion pump to administer the blood over 6 hr c. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion d. Flush the blood administration tubing with 0.9%sodium chloride prior to the transfusion 105. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider? a. Sedation b. Shuffling gait c. Weight gain d. Dry mouth 106. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? a. Ride a tricycle b. Kick a ball forward c. Hop on one foot d. Climb stairs with alternate feet 107. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? a. Share personal options to help influence the group’s values b. Measure the accomplishments of the groups against a previous group c. Yield in situations of conflict to maintain group harmony d. Use modeling to help the clients improve their interpersonal skills 108. A nurse is assessing a client who is 2 hr postpartum for uterine atony. Which of the following actions should the nurse take? a. Palpate the client’s fundus b. Evaluate the client’s pain level c. Monitor the client’s urinary output d. Check the client’s vital signs 109. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? a. Faintness upon rising b. Urinary frequency c. Bleeding gums d. Swelling of the face 110. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Monitor the FHR via Doppler every 30 min b. Restrict the client’s total fluid intake to 250 ml/hr c. Give the client protamine if signs of magnesium sulfate toxicity occur d. Measure the client’s urine output every hour 111. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Maintain eye contact with the newborn during feedings b. Minimize noise in the newborn’s environment c. Administer naloxone to the newborn d. Swaddle the newborn with his legs extended 112. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A 16-hour-old newborn who has yet to pass a meconium stool b. A 2-day-old newborn who has a mall amount of blood-tinged vaginal discharge c. A 2-day-old newborn who has a respiratory rate of 70/min d. A 16-hour-old newborn whose blood glucose is 45 mg/dl 113. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness 114. A nurse is caring for a client who weighs 75 kg. the client has a prescription from a dietitian to decrease calorie intake by 500 cal/day for 25 weeks to produce a weight loss of 1 pound per week. What us the expected goal weight for the client in pounds at the end of the 25 weeks? a. 140 pounds 115. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? a. Place the client upright on a donut-shaped cushion b. Teach the client to shift his weight every 15 min while sitting c. Turn and reposition the client every 3 hr while in bed d. Assess pressure point every 24 hr 116. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum creatinine c. Serum potassium d. Liver function test 117. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? a. WBC 9,800/mm³ b. Creatinine 0.9 mg/dl c. Fasting blood glucose 108 mg/dl d. Potassium 5.2 mEq/L 118. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client? a. Canned barley soup b. Potato pancakes c. Wheat crackers d. White flour tortillas 119. A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure? a. Compare the client’s current weight with preprocedure weight b. Confirm that the client is able to urinate c. Check the client’s serum albumin levels d. Examine for leakage at the site of the procedure 120. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices”. Which of the following responses is the priority for the nurse to state? a. I realize the voices are real to you, but I don’t hear anything b. What are the voices telling you? c. How long have you been hearing the voices? d. Have you taken your medication today? 121. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? a. The client is exceptional clingy to others b. The client exhibits impulsive behavior c. The client might act seductively d. The client is overly concerned about minor details 122. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent form the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? a. A client who fractured a femur yesterday and is experiencing shortness of breath b. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs c. A client who sustained a concussion and has unequal pupils d. A client who is postoperative following a bowel resection with an NG tube set to continuous suction 123. A nurse is caring for a client who request to wear her own clothing while ambulating in the hallway. The nurse is demonstrating which of the following ethical principles when she respects the client’s decision to wear her own clothing? a. Nonmaleficence b. Justice c. Veracity d. Autonomy 124. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Whole grain bread b. Avocados c. Smoked salmon d. Pepperoni pizza 125. A charge nurse on a medical-surgery unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who is receiving heparin for deep-vein thrombosis b. A client who has cancer with a sealed implant for radiation therapy c. A client who has COPD and a respiratory rate of 44/min d. A client who is 1 day postoperative following a vertebroplasty 126. A nurse is auscultating heart sounds of a n adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the finding? a. Pericardial friction rub at the pulmonic area b. Fourth heart sound at the aortic area c. Third heart sound at the tricuspid area d. Murmur at the mitral area 127. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Hypertension b. Epigastric pain c. Vomiting d. Contractions 128. A nurse on an acute care unit has received change-of-shift report for four clients. Which of the clients should the nurse assess first? a. A client who has an elevated AST level following administration of azithromycin b. A client who has a fractured left tibia and pallor in the affected extremity c. A client who is 1 hr postoperative and has hypoactive bowel sounds d. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses 129. A nurse is obtaining a client’s medical history before initiating 1,000 mL of 0.9% sodium chloride with 20 mEq/L potassium chloride IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? a. Multiple sclerosis b. Advanced cardiac disease c. Chronic alcohol use disorder d. Severe renal impairment 130. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Serum creatinine 0.8 mg/dl c. Prealbumin 10 mg/dl d. Calcium 9.5 mg/dl 131. A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. The PCA will deliver a double dose of medication when you push the button twice b. You can adjust the amount of pain medication you receive by pushing on the keypad c. Continuous PCA infusion is designed to allow fluctuating plasma medication levels d. You should push the button before physical activity to allow maximum pain control 132. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Obtain trough level 30 min after the medication infusion b. Give the dose over 60 min c. Inject 1%lidocaine prior to each dose d. Administer the medication undiluted 133. A nurse is caring for a client who has type diabetes mellitus. The client reports that is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (select all that apply) a. Diaphoresis b. Acetone breath odor c. Tremors d. Inability to concentrate e. Polydipsia 134. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery b. Administer analgesics on a scheduled basis for the first 24 hr c. Give cromolyn nebulized solution every 8 hr d. Apply a warm compress to the operative site every 4 hr 135. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Administer calcium gluconate IV c. Prepare an IV bolus of dextrose 5% in water d. Administer methylergonovine IM 136. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? a. Repeat the dose if your child vomits within 1 hr after taking the medication b. Limit your child’s potassium intake while she is taking this medication c. Have your child drink a small glass of water after swallowing the medication d. You can add the medication to a half-cup of your child’s favorite juice 137. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? a. A 15-year-old client who is 6 hr postoperative following a herniorrhaphy and reports pain at the IV infusion site b. A 3-month-old client who is 1-day postoperative following cleft lip repair and has a pulse of 120/min c. A 12-year-old client who is 2 days postoperative following an appendectomy and is refusing to ambulate d. An 8-year-old client who is 12 hr postoperative following a tonsillectomy and is experiencing frequent swallowing 138. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” Which of the following responses by the nurse is appropriate? (select all that apply) a. Let’s talk about your mom’s cancer and how things will progress from here b. Tell me how you are feeling about your mom dying c. Tell her not to worry. She still has plenty of time left d. You sound like you have questions about your mom dying. Let’s talk about it e. Hospice will take good care of your mom, so I wouldn’t worry about that. 139. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure twice a day b. Administer a bronchodilator after the procedure c. Perform the procedure prior to meals d. Hold hand flat to perform percussions on the child 140. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? a. The cord stump will falloff in 5 days b. Contact the provider if the cord stump turns black c. Clean the base of the cord with hydrogen peroxide daily d. Keep the cord stump dry until it falls off 141. A nurse is preparing to perform a sterile dressing change. Which of following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on a clean surface b. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field c. Set up the sterile field 5 cm (2 in) below waist level d. Open the outermost flap of the sterile kit toward the body 142. A nurse is caring for a client who has acute glomerulonephritis. Which of the following should the nurse expect? a. Hematuria b. Weight loss c. Hypotension d. Polyuria 143. A nurse working in an acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. Euphoric mood b. All-or-nothing thinking c. Disorganized speech d. Hypochondriasis 144. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Applying a condom catheter for a client who has a spinal cord injury c. Administering oral fluids to a client who has dysphagia d. Reviewing active range-of-motion exercise with a client who had a stroke 145. A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hr to a newborn who weighs 4.34 kg (9.5 lb). Available is ampicillin 125 mg/ml. How many milliliters should the nurse administer per dose? 17 ml 146. A nurse is delegating tasks to an assistive personnel for a group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology b. The client in room 109 has spilled his water pitcher c. Tell me the standing weight of the client in room 102 before breakfast d. Take the vital signs of the clients on this side of the unit 147. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension b. Primary glaucoma c. Osteoarthritis d. Amputation 148. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Monitor the child’s cardiac status b. Gives scheduled doses of acetaminophen every 6 hr c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom 149. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the Aps a. Evaluate the AP’s performance of each task (4) b. Review the skill level and qualifications of each AP (1) c. Monitor progress of task completion with each AP (3) d. Communicate appropriate tasks to the APs with specific expectations (2) 150. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following strategies is appropriate for the client? a. Tape stockinet over monitoring devices and cords b. Remove stopcocks from IV tubing c. Schedule the client as the last surgery of the day d. Disinfect and powder any latex products before use 151. A nurse is assessing tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? a. Perform postmortem care b. Suction a new tracheostomy c. Remove an NG tube d. Change a dressing on an implanted central venous access device 152. A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture? a. Place a towel roll under the client’s neck b. Position a pillow under the client’s knees c. Align a trochanter wedge between the client’s legs d. Apply an orthotic to the client’s foot 153. A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will perform the exercise once each day before bed b. I will alternately contract and relax m gluteal muscles c. I will try to hold my urine for a little while after I first feel the urge to urinate d. I will determine which muscles to contract by stopping and starting my stream of urine 154. A nurse is caring for an adolescent who has hyperthermia. Which of the following is an appropriate action for the nurse to take? a. Initiate seizure precautions b. Cover the adolescent with a thermal blanket c. Submerge the adolescent’s feet in ice water d. Administer oral acetaminophen 155. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? a. Hypovolemia b. Cardiogenic shock c. Hypotension d. Left ventricular failure 156. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Explain the risk of leaving b. Summon a security guard c. Notify a special worker d. Complete an incident report 157. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? a. Attach the restraint to the bed’s side rails b. Request a PRN restraint prescription for clients who are aggressive c. Document the client’s condition every 15 min d. Remove the client’s restraint every 4 hr 158. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? a. Exhibits separation anxiety b. Suspicious of others c. Ritualistic behavior d. Preoccupied with aging 159. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the client indicates an understanding of the teaching? a. I will remove peanuts from my diet b. I will remove gluten from my diet c. I will remove bananas from my diet d. I will remove dairy products from my diet 160. A home health nurse is caring for an older adult client who reports, “I keep coughing when I try to swallow my food, but not at other times”. Which of the following actions should the nurse take? a. Initiate a consultation with a speech-language pathologist b. Encourage the client to increase fluid intake when the cough is present c. Recommend an antitussive 30 min prior to each meal d. Instruct the client that this is due to increased salivary flow that occurs with aging 161. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tubs while wearing the patch b. Apply the patch to your forearm c. Avoid high fiber foods while taking this medication d. Remove the patch for 8 hr every to reduce the risk of tolerance 162. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. Feelings of dread b. Heightened perceptual field c. Rapid speech d. Purposeless activity 163. A nurse is teaching a parent about safely securing her 3-months-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? 164. A nurse is preparing to remove an IV catheter form the arm of a client who has phlebitis at a peripheral IV site. Which of the following actions should the nurse plan to take? a. Express drainage from the IV site and send it to be cultured b. Apply a pressure dressing at the IV site c. Place a warm, moist compress on the site d. Insert a new IV catheter distal to the discontinued IV site 165. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. Your desire to be an organ donor must be documented in writing b. You must be at least 21 years of age to become an organ donor c. Your name cannot be removed once you are listed on the organ donor list d. I cannot be a witness for your consent to donate 166. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Platelet count b. Urine ketones c. Serum potassium d. Total bilirubin 167. A nurse is conduction an initial assessment of a client and notices a discrepancy between the client’s current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client’s medical record b. Contact the charge nurse to see if the prescription was changed c. Compare the current infusion with the prescription in the client’s medication record d. Submit a written warning for the nurse involved in the incident 168. A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Polyuria b. Tachypnea c. Pruritus d. Hyporeflexia 169. A nurse is planning to administer atenolol to a client. Which of the following should the nurse assess prior to administering the medication? a. BUN b. Respiratory rate c. Blood pressure d. aPTT 170. a nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? a. I need to have an enema before the test b. I will drink an oral glucose solution during the test c. I should urinate before the test d. I will lie on my left side during the test 171. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Contact the family by phone b. Implement the nursing process c. Clarify the source of the referral d. Schedule a time for home visit 172. A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider? a. Decreased appetite and irritability b. Sunken fontanels and dry mucous membranes c. Temperature 38 C (100.4 F) and pulse rate 124/min d. Pale and a 24 hr fluid deficit of 30 ml 173. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? a. Offer high-calorie, high-protein snacks to the client b. Weigh the client once each day c. Encourage the client to eat foods selected by the dietitian d. Recommend the family provide the client privacy during meals 174. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure b. Position the client over an overbed table prior to the procedure c. Initiate NPO status 4 hr prior to the procedure d. Administer 1L dextrose 5% in water IV bolus prior to the procedure 175. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? a. Zolpidem 10 mg PO one tablet at bedtime b. Hydrochlorothiazide 12.5 mg PO BID c. Triamcinolone acetonide 100 mcg/inhalation two puffs TID d. Lorazepam .5 mg PO one tablet daily 176. Exhibit Question 177. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? a. The estimated blood loss was 250 ml b. There was a total of 10 sponges used during the procedure c. The client is a member of the board of directors d. The client was intubated without complications 178. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the forms? a. Explanation of the procedure b. Possible alternative treatments c. Potential complications d. Expected outcome of the procedure e. Cost of the procedure 179. A nurse is caring for a client who has heart failure and is receiving continuous IV infusion of low dose dopamine. Which of the following is the highest priority? a. Erythema 5 cm (2 in) above the IV site b. Pedal pulse of +1 bilaterally c. Blood pressure 92/68 mmHg d. Urine output 35 ml/hr 180. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? a. Encouraging a client to use jet hydrotherapy on her lower back for 1 hr b. Instruct a client’s partner how to apply counterpressure to the client’s sacral spine for 30 min c. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen d. Using effleurage on a client’s lower abdomen &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& & 2. A nurse is caring for a client who is a rabbi, which of following activities should b e included in plan of care to incorporate religious belief? -Assign client to a private nurse -Assess clients nutritional needs and preferences -Limit the client's visitor's family members -Arrange fcir client to visit hospital's spiritual advisor .? 2.After client visits a -Evaluate and document what the client -Give the client a -Albumin E. Which of the following laboratory findings indicates the client is at risk for complications following a thorancentesis? -Sodium 136 10 -Glucose 100 4. A nurse is caring for a client with nursing diagnosis Irrfaired swallowing following a CVA, which of the following nursing impleme' tionis appropriate for the client? • -Provide endotracheal suctioning -Place in Fowler's -Offer clear liquids -Restrict fluid intake 2 A nurse is caring for a cliqnt who gave birth 10 hours earlier. The client is in the taking in phase of maternal adaptation. Most appropriate intervention at this time? -Instruct client about infant and self-care -Encourage mother to send her infant to the nursery so she can rest -Listen to mother's verbalization of pregnancy and birth experience -Provide opportunities for mom to. be independent in self care 6.A client is receiving radiation therapy as treatment for breast cancer. Which findings. indicates possible development of hypercalcemia as a complication of radiation therapy -gastric distress and renal calculi -periorbital and facial edema -dyspnea and epistaxis ,erythema and flushing of upper body 7.A client is receiving several different medications during an inpatient stay in a health care facility. Which medications should be suspected when client begins experiencing severe diarrhea? -Oxycodone -Celphamine (M .) -Al buterol -Hydrochlorthiazide ( HydroDuril) 8.A female client with several stage 4 pressure ulcers is undergoing treatment as prescribed by the wound_care consultant. Which findings to the nurse indicates that client's plan of care needs revision and consultant should be contacted? -loss of 2.3 kilograms(5bs) over past 7 days r: -serum albumin level of 4.0 4. -hemoglobin of 12.3 -appearance of bright red tissue under eschar A nurse is caring for a client in a long term care setting that provides restorative care which of the following is appropriate when assessing client's ability to perform ADLs' -observe client for signs of aspiration when swallowing review PT notes regarding activity tolerance assess client's level of participation in social activities Vmonitor client's ability to perform hygience care E. A client is admitted with suspected GERD upon receiving the client's admission laboratory results the nurse notes a troponin level of 0.6ng/DL. Based on this finding the nurse should expect which of the following additions to the client's pland of care -obtain bedside chest xray -maintain fowler's position -send blood for type A crossmatch vprovide oxygen via nasal cannula 6. A client with HIV admitted to the med surg unit with a respiratory infection, the clien'ts family members requests fresh flowers be placed in the room everyday. Which of following is the appropriate nursing action? -allow flowers because they will keep client's spirit up -request that the family bring artificial plants instead uteach that family fresh plants of any type are prohibited -instruct family that any flowers must be placed away from client's bed D. During the administration of conscious sedation, a client respiratory rate of 9/min. Client does not respond when asked to lift her right hand, which nursing action is indicated by these findings/ -document and continue to monitor — "administer oxygen and agents -provide fluids and vasopressors -insert an airway and suction 13. A nurse is-nceargiantgivfeorEaLcISliAentewstith AIDS wh"o-is-;--arliral values indicate the client is responding to treatment -elevated plasma 1-1IV-1 RNA viral load E. -increased CD4 and lymphocyte count • -positive Westernblot 8. A nurse is caring for 4 clients who have been prescribed various nonpharm interventions, the nurse should intervene first for which of the following clients. V -client who is 3 days postop, prescribed icepacks, and rates his pain at 5 out of 10 -client with second degree burns to hand who is asking that her favorite dvd be turned on so she can watch it while her dressing is being changed -client who has degenerative arthritis in joints of both hands, and is asking for a nightly hand soak in warm water before going to sleep -client with Alzheimers disease is pacing, pulse 110/min and BP 142/90 and has respirations and has responded well in the past to music therapy D. A hospice nurse is making home health visits, which of following findings indicate effective coping -client laughs uncontrollably during a home visit -client communicates a plan to go backpacking in Europe next year V-client is communicati ng funeral preferences to family members -client reports that he doesn't need help with ADLs E. A cli ent ho spi tali ze d wit h pn em oni a is demonstrating difficulty talking and remaining asleep -adminster a sedative medication at bedtime encourage ambulation one hour prior to sleep warm cup of cocoa at bedtime environmen biz.4 P2_46-v- 3Q, e y17. A one year old child is prescribed ibuprofen when having a febrile seizure. Nurse teach parent best way to admin med is -chewable tablets V -elixir -enteric coated tablet upp ository 18. When preparing client for lumbar puncture 1 -lie on examining on stomach -sit on edge of table and lean forward V -lie on your side with knees to your stomach -kneel with your head resting down on your folded arms 19. Which of foil manifestations should nurse expect to find whose blood glucose of 650 -shallow respirations -headache V-fruity breath odor o -cool, clammy skin / 20. Nurse is caring for cli ent with depression, prescribed TCA antidep?essant, which of following statements indicated adverse effect that should reported to primary , care provider -mouth constantly dry since starting med -I have been drowsy in the morning -cant urinate for several ho a-my eyes have been sensitive to sunlight lately(look it up) is scheduled for laproscopy surgery at 1400, At 1100 surgeon visits and --estifter 5 min with informed consent Client states doesn't understand surgeons explanations, what should nurse do? E.-call Surgeon and requests he return to client's room to provide clarification -tell client he will obtain more information b4 surgery -explain the procedure to the client and complete document -call the operating nurse and delay the surgery O Upon admittance to hospital a client states she does not have a written advance directive. After completing admiss assess, nurse explains should complete an a.dv directive because: -decrease liability for client's family, hospital, hospital employees, L/-guides primary care provider in planning care for individuals in accordance with their wishes -avoids the uncomfortable discussions at end of life care-with the family and hosp staff -finalizes client decision regarding life saving measures 23.A nurse is evaluating effectivess of nonpharm mangt for a client. Which of following findings indicate interventions is effective (/ -client falls asleep after back massage -client rates pain 5 out of 10 after application of heat -client heart rate is 90/min and irregular during a 30 minute therapy session -client is observed relaxink muscles while meditating ? A nurse is caring for client post op. Client reports pain level of 10/10 at 8:30, based on the pain assess finding and the client's information provided the nurse should take which of the following actions next. 12. - call the primary care provider for analgesic intervention -give Tylenol as prescribed -obtain pulse oximetry reading -administer a sliding scale of insulin B A client is admitted to the ICU vv/ head injury, the ICP is being monitored via an intraventricular catheter, which should nurse include in client's POC? -maintian ICP at 20mmHg v'-avoid overstimulation of the client -suction client every 2 hours -keep client in a supine position -at the hospital -outdoors E. A nurse who is the first respondent to a biological attack, recognizes that decontamination should preferably be: V-near the site of the exposure -in a shower -Gentamycin -Warfarin -Albuterol O A nurse should carefully monitor client's taking Furosemide (Lasix) and which of the following medications: E. yvt:a 2 Nurse is assessing a client who is 36 weeks gestation, which should nurse report to provider? -protruding hemmrhoids -urinary frequency V-3-1- deep tendon reflexes -supine hypotension 15. When developing a client's trust, the nurse should give priority to which of the following nursing interventions -facilitate problem solving with the client -set firm limits and boundarie s with client -invovle the client in group dicussions .j-ensure the confidentiality of the client's information E. A nurse is collaborating with other staff nurses to determine staffing needs for a surgical unit, currently the hosp is using a client's identification to determine staffing levels. Which of the following data is most important in planning for optimal staffing? -preference of staff nurses and what shift are desirable -time of day that most client's return from the operating room -state board of nursing rules and regulations regarding minimal client nurse -method used to staff surgical unit in. B A nurse is caring for a client who is febrile. Reduce fever by giving cooling blanket, which indicates having adverse reaction? -flushing -restlessness -tachycardia -shivering/ Client wants to review medical chart, ask nurse to see it, or tj -you have a legal right to review your medical chart -primary care provider must give permission -should speak to primary care provider, because chart is written in med terminology -request to review must be made in writing 17. .client in crisis d-Help client refocus and find constructive ways to cope -Have participate in individual psychotherapy -Assure that solution will soon improve - Encourage to express feelings in group therapy E. C li e n t i s r e c e i v i n g o x y t o c i n ( p it o c i n ) t o a u g ment labor, which findings indicate to nurse that current dose of oxytocin should be maintained (J-fetal heart rate increase of b_ts per min with contractions -resting tone of uterus greater than -cervical dilation of lcm/hour in the active phase -contractions occur less than 60 secs (go— ) 0 sec ) 19. A nurse is dev a discharge care plan for client who has osteoporosis to prevent - injury nurse should instruct client to -avoid sitting in one position for prolonged periods I I( -perform weight bearing excercises### _ Ket k, cie_s• -splint the affected areas ---avoid crossing the legs beyond the midline 0— icfrbee4e iie„olot-04" c 11 E. while assessing a client in labor the nurse observes that the umbilical chord protruding from the clients vagina after calling for assistance and requesting that the primary care provider be notified the nurse should immediately 20. prepare for emergency c section 21. prepare the client for an administration of lactated ringer solution c position the client on her side and insert a sterile gloved hand into the çJ vagina to take pressure off the chord 5 rt_ -v\-A-/) p-reiNsuw-e, QCf p.ris yvt-j) s 0, \cx,r. ° c": 6er\ SC6Vosi s a v-eAso2 *\ odleft I Ccki1/4-\=i,c, OQ ts•-\ fvv) 'rck:‹e ‘)./%, •(:03 d measure the clients vital signs and fetal heart rate and increase the iv flow rate K)‘cks---)'NJ6 as pcfa,v-e}o\Q\ cd ) Alo N In e ask._ • 1icc)38S —>= Low s s A Ci C 37 a nurse is preparing a client for discharge with a ? presecribtion for aldactone. The nurse should instruct the client to limit the intake of which of the following foods V 1. banannas and citrus fruits 2. lobster and organ meat 3. milk and cheese 4. beef and butter 38 a nurse is to perform a dressing change for a client with a burn wound identify Fri/(ve the sequence the nurse should follow. (this one you put in order in the box) 1 medicate with analgesic1 11,4A4- .11 g':•\3 2remove previous dressing2 -3— 1/4-s.94,5 fr px6mAg.._ c.L 3assess for edema draininage and discharge3 Ar al ltki:AlcuA24, 0•-••••'-‘40c7.11 -c 4observe wound as prescribed5 — C& 0-4 t;:-c- 5'• O apply a thin layer topical antibiotic ointment as prescribed4 21. when performing a mental status examination the nurse should recognize that which of the client finding indicate impaired vnition 1.the client is withdrawn and avoids eye contact O the client is observed grumbling to herself 22.the client frequently asks where am i D. the client has slurred speech JJA VS)( 23 4Zio,--YvkoY.Fisy-1 —3 wa eiVi 61 V/5 Ac1-1 40. A nurse is working on an orthape ct surgical unit...where slide back chairs are used to assist client to get out of bed and increase mobility, there are not enough chairs to serve all the clients , which of the following actions is important for the nurse to take 1. develop a rotational schedule to get clients out of bed 23. borrow available equipment from other clients 24. modify client care plans to decrease unnecessary use of chairs -4k fiC Avol NeN ±k'rn\D)`A -e- ct\ caAY1 c (1141/\6-As-i'c_ -T1 LUO--- v6a._ \ czt- c. ta.0_,L4 01/4..con sti pod-icsv.Tt a n y\ r„-,eccu_iya vs .6-6 it -fi e)j Q- •3 v;,,- zsice V\-°`^s6Q- 1-Lcd- 115 Vce _ --N-Lx4204-e- tAr yytckwe _5 P - riz,64-1, 4 1-1aS_ Vie need for further equipment to meet client care demands v cg a client if reviel.rieng a epoetin alpha (epogen) for treatment of anemia secondary to bone cancer which of the following client findings indicate hematopoesis growth factor treatment has been effective? ( the client does not experience hypertension during therapy 24. 2. hemoglobin level are with in normal limits 3.the client denies not experience bone pain during therapy 4. neutrophil counts are elevated. 42. while visiting a family health clnic a 19 year old ... regarding the correct use of condoms. Which of the following statements made by the nurse is correct 1. ensure that the condom fits snugly around the tip of the penis O condoms are equally effective for birth control With or with out the use of vaginial spermicides F.3. when using implanted contraceptive methods condoms should also be used to protect against STD's 4. use of petroleum jelly based lubricant with the condom increases effectiveness of condom 25. a nurse is assessing a client who is near the end of her first trimester during the routine prenatal exam. When checking to determine whether or not the fetal heart rate can be detected the nurse should 1.Use a Doppler stethoscope to hear the fetal heart beat just above the umbilicus E.Count the fetal heart beat and not the quality and rhythm in conjunction with uterine activity 1." 3. Move the fetal scope along the midline just above the pubis while applying firm pressure 26. Perform Leopold's maneuver to palpate fetal position and determine location of the fetal heartbeat 44. A client is admitted with a history of transient ischemic attacks. To prevent injury while hospitalized, the nurse should -Keep the four side rails up on the clien'ts hospital bed 1\ 4L5-c4 cifiA 'Ols )orls24,. cu,e• 4,0,c1A) (5'r\ b 004K- off5Thok.k. Z7y-, yNs2_,,,OocsNry-) e —YIN 1 4K-cc D.:(>Qc0 .1( filaX • cf-vt_az--4- 100c , cc— tip staL6- • ----ay \d' Co•39 G- c_0-0 ct fe-g o 1,tio ors-4-Ezci. a MS A WEC -lesj 6 a_ ci C ra4-c,k2 /,212_3( E. r Q_ sleep the client a sedative at night to promote 0_0 ve admission V- complete a fall risk assessment upon night with the client -encourage a family member to spend the 27. A nurse is providing pallative care to client and family. Which of pallative care family indicates understanding die at home -im relieved my father Will my father pain cx c> \-i2n Bc31/4 staterne cp, 28. cWej- - ./the nurse will help relieve be prolonged my father's life can now I will discontinue my father's charopriatic treatment -vomiting blood E. A nurse is caring for a client with GERD, which of foil assessment findings should nurse expect to find v-atypcial chest pain -rebound tenderness -shortness of breath 47. A client is prescribed 500 mg penicillin IM, the 2gm of pen in vial should be nurse should check that diluted with 10m1 of normal saline before admin the nose, )/ vi N V there are how many ml in syringe ICT1.) 4r i, ... - \ 1 t 6-C S- -0.25 30 - -0.5 -2.5 -5 caring for a child with a new onset of teaching child seizures who is about to and 48. A nurse is which of the following should be included in procedure undergo an EEG, parents about the -make child NPO night before procedure c 0 , , (--)c Lke-- C d-1- ylAdjA NKS:v —3 AC e)-t_ci-lo•--) (--Am cy,t1 AfitS .44 1-1-ness, cilc72-/4es.s ? 0 s to0 -}..e, s vv.\eA 0 fi frekeve ) am cI biard r/a 4,3Q rce.._ ei.):cce_cy k4,1., k ircen t7-wash child's hair with mild shampoo prior to procedure -give child Acewminophen for pain following procedure -keep child out of sun for 4 hours following procedure 29. a nurse is caring for 4 clients who are scheduled for surgery today, which a following indicates that a client needs further intervention b4 surgery -a client whose lab values are hemoglobin 11.1 g/DL and potassium 3.8m eQ/L -a client who has not completed an advanced directive E.client's 1NR 2.1, PTT is 2 times the normal value -a client who has not had anything to eat or drink for eight hours SO. Which of the following assessment following indicate proper use of crutches by a client? -client supports body weight leaning on axillary crutch pads V-client's positions hands on grips with elbows slightly flexed -client places crutches on affected side when getting up from a chair -client customizes the crutches for personal fit . A nurse is planning discharge teaching for a client who will continue receiving chemo for treatment of leukemia in the outpatient clinic. Which of foll should nurse include .avoid salads, raw fruits and veggies -take aspirin for fever greater than 38 degrees C (104 F) -use new thinking glass everyday -monitor and record temp weekly 52. Which of the foil nursing actions is an example of safe cost effective care -Change peripheral IV tubing daily for a client with DS 1/2 NS infusing at 100m1/hr -Bring in two sets of blood infusion tubing at start of the transfusion of 3 13 of blood -Initiate IV heparin therapy without the use of IV infusion pump move unused IV infusion pump from the client's room 32. An adolescent who is being seen in the outpatient clinic reports she has had a low grade fever, headache, sare throat, swollen lymph nodes for about four days. This morning she developed a pinkish red macular popular rash on her face and neck. Which of the following is an approprate nursing action -admin aspirin to her for the low grade fever -isolate her from any pregnant woman -begin to monitor her for resp distress -give immunoglobulin to prevent transmission A client is being transferred from one health care facility to another. To ensure continuity the nurse who is transferring the client should give priority to inclusion of which of the following information -the client nursing care -list of me44.dmin to client during the hasp stay -the client yits igns records ssessment of the client's tolerance of physicatuthdty E. A client in ESRD has a serum potassium o f6.2mEQ/L. The nurse should anticipate implementing which of folio interventions first? -give Furosemide (Lasix) -admin IV fluids with dextrose and regular insulinc -initiate continuous cardiac monitoring -777777777777777 Pilts., 33. A nurse is providing discharge instructions to the parents of a newborn. Which of following instructions regarding newborn safety is most important for the parents to understand? -arrange for a child care provider who is trained in infant CPR -install baby monitor in the newborn's nursery and parent's bedroom ..ice the newborns temp under the arm if signs of illness are evident vsecure the newborn in a rear-facing approved infant car seat when riding in a motor vehicle 6. A nurse is caring for a client on his first day after having knee surgery. Morning assessment reveals a pain level of 8/10 and bp of 180/90mmHG. Which of the following nursing actions should nurse take first? -admin antihypertensive med vadmin pain med -reassess bp -document the blood pressure 34. A nurse should give priority to which of the foil interventions when initiating IV anitmicrobial therapy v-review the clients allergy history -gather the necessary supplies -explain the procedure to the client -Assess the veins in both of clients arms 59, A school nurse is performing scolosis screening. Which of foil clinical signs will be evident in a student who has scola77- -mild pain in hip region N./ -uneven shOulder and pelvic height -limited range of motion of hips -uncoordinated gait E. A nurse is positioning a client for Cesearen birth. To prevent a compromise in placental blood flow during the intraoperative period, the nurse should -assist the client into the lithotomy position 1Y1-0 GtA.C2V176)1 ) 61j1 1--cX 1Scs 5- t-o 1-0, -roc° —T- 'I-place a wedge under one of the client's hips -insert a pillow under the client's knees -positiorrthe client in reverse Trendelenburg 35. A nurse is providing care to a client who has Hep A. Nurse should recognize which of following nursing actions poses risk for transmission of the disease -collecting a blood sample -feeding the client V- emptying the fecal matter -changing saturated IV dressing E. During a well child visit for folll when discussing age specific The nurse should include which of the rovutliand dev? it is normal for your child to experience separation anxiety at this age 777777?" -your child should begin to play cooperative with other children Vit is normal for your child to...say whose and and pronounce single syllabus words at this age -your child may begin to become self conscious about her appearance C. A nurse is evaluating whether an inservice for the organiz structure of the unit was effective. The staff have been heard complaining about the charge nurse not being assigned clients. The nurse can accurately deduce from the responses that the -inservice was not successful in educating the staff about the change L/-inservice needs to be repeated so staff are more clear on the proposed change -staff will accept the change,as soon as they have time to adjust -staff are reacting emotionally with anger to the change presented in the inservice B A client is to receive a puendedal block while giving birth. The nurse should expect that a puendal block will CzNec ck-C 'se)" wseolt --Vowkris pc. Bo • h-zr,„ - A-3-" -C&ANk trere'142 6c) -t kcA* `S.c` C-4D6 es i-P -frYfir% _.0-/bc)\,No_ ..eve.Qc& inr 6 k/ P° -kt'"r:ri 5144 .&' 6 14...1 Kruzs. 1.- -411.. t-e4 77'29117 Adwv:As 4-- e QS-tielt, a -f k-Ortle 5 ik) -block the pain of uterine contractions `.k c'Ytt 4 .14/nAs/sfiso,11 \--\<=.Z 3b•-•* ) 1j-diminish pain in the perineum -1.-c\cfck cs'Y ca-e--v. -need to be given atleast one hour before delivery \es cAc ez.•(-‘ -e 142_ Xei3A- -increase maternal blood pressure e „,%e. , I'''‘' -4 2e. ote_ZycQp... . _ N-1174:cA-4-1 4-5et.44 yi. e 1 e_ vet,140, 65. Which of the following statements by a parent of a newborn indicates that cr oe-uPe_cl e. discharge teaching regarding care of a circumcision has been effective? -I will wash off any.discharge that appears on the base of the penis 'P th 01tie...,Jats k -I will give my baby sponge until the circumcison has healed \ylcp — ch:tfiliz -I will cleanse the penis with soap and water with each diaper change p Fekswt -I will call the physician if my baby doesn't urinate every two hours "42 sid.e.. citec. - it'll". CA-a.-d ) 66. A nurse is providing discharge instructions to the parent of a newborn. The ''/& - nurse determines parent requires furtliteaching regarding use of a bulb syringe if 1/ 1 e she states -I will suction the baby mouth before I suction his nose E. -I should insert the syringe in the center of his mouth -I should compress the bulb before inserting into mouth -I will keep the bulb syringe near my baby's crib 38. The nurse is teaching a client with GERD about omerprazole (Prilosec). Which of the following indicates a need for further teaching? -I should take it before breakfast t-it will decrease the pH level in my stomach -iineeded I can take antacids as long as I wait two hours after taking Prilosec -I should have relief of my heartburn within several days of use E. A nurse is caring for a client w/ an indewelling urinary catheter. Which of the foil actions should nurse take to provide appropriate catheter care? ,sc,c;c.d pesonctl; Ick pe Ky\ - .000C Cl SO) —) e nSi -Hv .y)-)07Dc.) 5tA))1,-) / 14,a/LQ.5 `e- P cd -16)1 LAAj—e zs-V 13) AMety‘itkv.f pTsp -disinfect the catheter prior to disconnecting it from the drainage tube -empty the collected urine a minimum of once every 24 hours . -hang the drainage bag on the bedrail vprovide perinea' hygiene at least twice a day 39. A nurse is teaching a client who just had a repair of retinal detachment. Which of foil client statement indicates a need for further teaching will call my doctor if I have pain that occurs with nausea -I will refrain from straining during bowel mvmt or when blowing my nose -I can resume my normal diet Li -I can do quiet activities such as reading or sewing 40. A nurse is caring for a client who is receiving continuous tube feedings via a NG tube. The client appears restless and abdomen is distended. Which of foil actions should nurse take first? -reduce the rate of tube feeding -notify the primary care provider V-check the residual volume -place client in a side lying position E. During assessment of a client with pneumonia. The nurse documents the following findings: • Client alert, oriented, restless BP is 148/65mmHG Oxygen saturation of 86% (while on 02 at 2L/min per nasal cannula Heart rate is 94/min Respirations is 24/min 0-eo a ctQoki jineyy4 --bcdoy e kAl-e_AA'c co c<k4 /2ered-i‘v-e_ +like ce\ s cc ck-Ie se ic )15y -4 \nec.,4 (ACC' , ---/vfc4(P0-"'' ^Ce-y cA. l eAc,_V-r-e04 ••••••Ii cd• iale/24;2 The client is curren y receiving IV at 100m1/hour and morphine sulfate,. Which of(:). the following actions should the nurse take next. -obtain an ABG E. -increase the oxygen flow rate -administer morphine sulfate as prescribed -Decrease the lv infusion rate 42. A nurse is caring for a client with fingerstick blood glucose level of 42mg/DL. Which of the foil findings is consistent with the lab values -hot dry skin -rapid deep respirations V -anxiety and confusion -nausea and vomiting cs2P"2' 1/4" 0 E. A nurse notices an unfamiliar staff member entering the obstetrical unit. Which of the following is the most appropriate intervention -stop staff member and verify identification -locate and notify charge nurse :check the staff member has a visible name badge -ask staff member if any help is needed 43. A nurse is caring for a client with Crohns disease receiveing TPN. Which of the foil findings is most indicative that the client is responding positively TPN therapy. -blood pressure of 144/74mmHg -Potassium level 3.3 V-average weight gain of 1Kg/day -no redness around central catheter site 44. A nurse is caring for a client who had a recent spinal cord injury and is quadriplegic. Which of the following assessment finding is a complication related to immobility -increased blood pressure V-crackles in the lower lung fields -hyperactive bowel sounds and diarrhea -diaphoretic skin E. A client had major abdominal surgery 24 hours ago. Which of the following is the best indication that postop nursing intervention have been effective in preventing resp complications -client uses incentive spirometer as instructed t/-client is able to breath deeply and to forcefully cough while splinting -client's temp without use of antipyretics has ranged from 99 to 99.5 -the client's pulse oximetry 93% 45. A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Nurse should recognize which of following indicates an adverse affect that must be reported to the primary care provider -client states "being in the sub hurt my eyes" V -client is observed displaying a shuffling gait while walking in the hall -client states I feel lightheaded when I stand up quickly -client is observed mumbling quietly while in the day room E. A nurse is planning care for an older adult client with a cognitive disorder such as Alzheimer's Which of the foil interventions should be included in the client's plan of care. Select all that apply 7" 7 " 7" 7779777 unsure about answer -set dear limits consistently when conduct is unacceptable -allow the client to choose between a variety of activities each day J -give client one simple direction at a time -establish eye contact and use touch when communicating with client Ni- reinforce orientation to time, place, and person . O A nurse is caring for a client who has just received the first dose of Lisinopril. Which of the following is appropriate nursing intervention E. -provide standby assist when client gets out of bed -provide foods high in potassium -place client on continous cardiac monitoring -monitor client's intake and output O Following a gastric resection, client experiences a cramping sensations, increased pulse rate, dizziness, and nausea, after eating a meal. To help reduce sx nurse instructs client: -consume plenty of high fiber foods at each meal -add carbs and diary products to the diet V -restrict liquids during, at least one hour prior to, and after meals _ -eat three large meals daily without snacking in between D. A diet reports to an RN that another nurse smells like alcohol Which of the following should the RN take next: -Complete an incident report outlining the client's observation _Ask the other clients assigned to- the nurse if they smelled alcohol -Suggest that colleagues on the unit observe the nurse throughout the shift for unusual behavior O -Gather any additional information from the client and then notify the nurse manager 48.82. A nurse for an older client who has chronic renal failure is prescribes acetaminiphen for fever. The nurse can expect that the dosage will be: E. -less than recommended does tlY)C-Q& -tkcic 604#1*mi'' f\U.)1 C PVC9IUVVQ- 0Lt Y) 4 -€ t - e ti t) "MC, ri-Lo WCA ip 80A) -the recommended dose - 1 times the recommended dose -2x the recommended dose • BT1wry d a Si a- -N M CE ck1 Cc riV2 oc./DIXZe-k fir r3V:5-U-f fc-L-04)1m . A nurse is admitting a months. Which of the client who is taking prednisone 10 mg daily for 10 following findings indicate a side effect of this medication therapy. t/'-thin extremities with obesity of the stomach 4c. 4( 1--k eit-ck,N-1 -bradycardia and postural hypotension 0 u I . / -swelling nd decreased range of motion of the joints 1 CV( /417-Inf-,52.7.1y1M) Q (Ne_ _spe_cAVc yckViijCsi Le3a -absence of hair on legs below the knees — W•42p-‘K, ?kik. SQ j-Tk Ckky C07:77 ) \Nip 5 ( -1-0LC ip up CO-01 0417 Jee it, c 4:4,MANA 49. A wife is acting as a primary care giver to heEmpuse with Alzheimer's disease who is homebound. The home health nurse recognizes signs of ineffective copin and caregiver distress. The nurse should take which of the followin actio initially: PQ emA pLse) -Assess the wife's competency to provide the care for her spouse - so (3 .)pi -Determine If their family members or friends available to provide assistan - 8c-ties i cntc-icle) Pe r."erci J-€01.2„ -Discuss the option of placing a spouse in a long term care facility - M .1 ( V -Provide information on local support groups for the wife to attend - cy e 5p-'J 97a- y-yj ,1.01 a 85 The nurse is caring fora client with herpes zoster. Which more teaching? of the following statements indicate • €'•11-/ "i1-0 td)Je the clients needs E. -I will apply astrigent compresses to the lesions three times a day -I will keep the lesion covered with a no_upsihesive dressing -4 will take Acyclovir to shorten the time for my pain I have this infection -I will take Ibuprofen 66. A child with diabetes mellitus has a o blood glucose level g/DL the nurse anticipates which of following actions a9-33.24\kYJCJ 6 Y -0,cti PY‘Q-cA --PG H1, ei•icy-em,„ . T - ckc \AA1 esx-olaok j-Request a bilingual Spanish-speaking female translator through the facility. 50. A nurse Is caring for a child with iron deficiency anemia. Which of the following lab values should nurse expect to find? -increased platelet count v -decreased hematocrit -increased hemoglobin???? -deceased HgA1C 95. A nurse is receiving the past medical history of a client admitted for agina. Which of the following is a risk factor for angina? eg`t(PA-s-.4 'CY)ck. cAN Ctrutz -COPD oppp./&,n'. V42 ner•Ga.vitik -seizure disorder -congenital heart disease nvo An..a Zc ).e Safi-eA i-hyperlipidemia cc4 YJe -"//ad- 2 Which of following findings best indicate that outcomes have been met for a client who has been physically abused by her spouse? -client spouse has agreed to attend anger mngmt classes at mental health clinic -client reports attending group counseling for abused victims at the mental health clinic V-client reports that she has a safety plan in place and will implement it when necessary -client spouse has promised to never physically harm his wife again 97.Nurse caring.for a client admitted with. fluid volume excess due to heart failure. Which of foil assessment findings validates client's hypervolemia has been resolved? -current weight maintained for 3 days -onset of polyuria fl effie) dmeboeige" . Ces 1?) ill a- )1c er 1- 0 1 C4 Al 144A SNOP-A-41441Y 1543 r)041 ..pl in CatAl - R -tes-Hx) 3 /4 Vol v-e- /72 e )Act kul-7)-y 19i 5erapi exP7_S ne Jpee, 'fr/c- s J2 h / y2 ,yz•N_..i.rc-eS ct- art., ‘.- fc€,V/A etjle ')\ e Cl" .149 1/14( - 2 atmd cAv-6Jc_ /leo evood -hematocn 3% \J-BUN 8mg/DL Nurse is assessing a preschooler who has recently experienced an unexpected death in the family. Which should nurse recognize as an expected finding? -child expresses curiousity about the death process -child refuses to talk about .the death tes-child believes the person will return -child has an increased frequency of temper tantrums A client who is receiving Phenytoin (Dilantin) for seizure disorder has been prescribed INI-1 and Rimfapin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? -client is having side effects to the combination of antimicrobial therapy -client is experiencing an adverse reaction to Rimfapin -client seizure disorder is nolonger under control -client is showing evidence of phenytoin toxicity CNA nurse is caring for a client who has undergone a modified radial mastectomy. A client has to Jackson Pratt drains. The nurse should -suture the drain to the client's bedding -report drainage greater than 25m1 in the first 24hours • -position the affected extremity below the level of the drain vrempty and compress the reservoir. A client who has a second-degree burn tells the nurse that the drsg changes are very painful. Which of the foil nursing interventions is appropriate? -allow client to determine when drsg changes will occur -use hydrotherapy on client's wound to remove old drsgs 51. -teach Client relaxation techniques to be used during drsg changes A 1,1 52. C 61577),..p coila-x- b _TL 5;-0-1) •exCQ - • 0 "V8i.ek.'--* (D 5C5 d" (-- S (5 1--> CC. 71-StAACAIC 7 -assure client the drsg changes will become less painful as wound heals E. Which of the following nursing actions appropriately maintains client confidentiality? -nurses lower their voices when a family member of a client approaches during a change-of-shift report -a nurse allows the husband of a client to see the client's chart after he says that his wife gave him permission -two nurses discuss a client's condition in an elevator after confirming that no visitors are in the elevator -a nurse removes an open chart from the nurse's station counter and places it Von the chart rack 103. When providing nursing care and support for a client with a gambling dependency. Which of the following is the most appropriate intervention. • -Assess the clients gambling dependency.and point out the clients use of defense mechanisms such as denial -Ask the client.to review his past incidents ofgambling and the negative feelings he experienced during those times -Help the client to gain awareness that he is responsible for his gamble dependency and needs to develop better impulse control V-Establish clients goals and have the client explain what actions he will take to prevent and manage gambling relapses ' 53. A client in labor is undergoing a vacuum assistive birth. Which f the following should the nurse perform at the conclusion of the procedure. -s, V Perinial assessment for trauma 10 5,--->t<z s Oki-oef c5S- 1,0 E. A nurse. delegates the task of ambulating to a client to an assistive personnel at the end of the shift the nurse discovers that the client has not beeen ambulated. The situation could have been best avoided if the nurse had: -checkea with the AP rnidshift to make sure thet the client have been ambulated .ce.4441- v r i e5K, ,5i‘-c5>) Jipp-op"),-e.t.p,)Cj ctA dek-Ck-+YY\i2t-J-- --c oad-tdou-ks-p-ots.fcuo4c1,-,,, ‘ 3.\ -5) 1) T 7 fz. $31):QVizt&YlcA e-\+.2)-FeiccLA/viVcsw colsz. \60,1t)S) 1)-e---'-8 t,P at the start of the shift what time he would prefer to ambulate the client chooses a more skilled AP to ambulate the client -emphasize to the AP the importance of ambulating the client 54. Which of the following interventions by the nurse to is most appropriate to decrease potential infections for a child with leukemia who is receiving chemotherapy. V -Screen and limit the childs visitors -Place gloves and gowns in the childs room -Assess the childs temp hourly -Offer the child juices that are rich in VIT C zsv, CockAssz d ledzs,Actr-t, E c .6 CketAr\40s •- 158. pc, tr(Jt) `ok reck) A client uses prescribed hydrocodone(vicodin) insisting oxycodone perkasett has resolved pain in the past. Knowing that the prescribed provider prefers hydrodone which of the follwing actions should the nurse take. E. a. explain the hydrocodone has been prescribed by the provider. Vb. inform the prescribing provider Of clients preference c.tell the client that he needs to discuss his preference with his provider d. have the client to try the hydrOcodone before judging the effectiveness. 56. a.nurse is caring for an infant with gatroentiritis which of the following assessment findings should the nurse report to primary care provider? a infant with temp of 38 c (100.50 and pulse 124 per minute. b. infant has decreased appetite and irritable c.infant.is pale and has 24 hour fluid deficit of 60 ml (.0)-0 ify2A,) ,a_ej-76:9 5ke • • j i t - tt) S *COO; CC-2C' CL re.416,4 Fma-AAA02 cs cd-- " 5}7.;' 117 )1 4 Ct72_, 5,0,bovid ez9CotiPra-V)-- a 0114 h* -ricuj 4-47.6&,— • P t•t"-5e „of da;*. Ac4-( - h doel cLA' 1- • pi2)21,9_5s2. co rd. Kns2x2 c keA4- p ii l)/1-6-)/t;kervs- Let, .E -FP--HIQ 5 t ceNe4 1Ne y, e"44),\.- i%s fita-cti .10 osol2", (455 )15i. /41e9-to (44.1*...crAt,Les 1*--eYpve. A nurse is caring for a client been discharged on weferin, which at the following home medication should the nurse question? *GC rc copme --NPH insulin, 18units every morning E 61/4) • --laxis 40mg k ra, y Lcce 'Kno_s2. --K+ 20mq p YeAk-eid-- al-ffir V --asprin 81mg -yr\iNNk-AlA'A cora 109 A client is diagnosed with an acute MI and is being treated with a thrombolytic agent and iv heparin in the emergency department which of the following finding indicates that the client is experiencing a satisfactory response to this intervention a.S2 heart sounds present V_01,6)1 b.q wave elevation is noted on the surface monitor tracings •ck-N () 1. A nurse is assessing the fontanells in a 8 month old infant which of the following is an expecxted finding v a. anterior font. Should be open b.posterior font should be open c.both font should be the same size d.both font. Should be molded, The nurse is assessing a client brought to the hospital psych services by a law enforcement officer the client has disorganized incoherent speech with , . • association and religious content client has flat affect, poor hygenen, repeptitive hand gestures the nurse recognizes these signs and symptoms as being most consistant with which of the following ( substance intoxication ( alzhemierS -disease ( depression ( schizophrenia 112. A client who is insulin dependent is.. which determines if the clients blood gluclose level is controlled? a. fasting &close of 60 mg b.postprandial glucose of 130 c. hct of 42 57. d• h alc of 6.5 113. A nurse is preparing to perform a sterile wound irrigation and dressing change for a client which of the folloyving actions by the nurse breaks surgical aseptic technique . setting the supplies in a sterile field and leaving a 1 inch parameter b. applying a sterile gown after applying a sterile mask 0— 1= 60-J9 I s+- c.putting on sterile gloves after preparing the sterile field os.(1 d. balancing the bottle on the sterile basin while pouring the liquid 1.14. A nurse is providng teaching for a family of an infant with decreased cardiac output with congenital heart disease which of the following for providing care should be included in the teaching a.maintain the infant in the supine position for sleeping or not being held b. perform infant care... frequently... intermittenly throughout the day \ bath the infant and change linens daily to reduce the risk of infection LiP•As2-4"-- • d. observe for signs of hunger such sucking of fist.., in order to feed infant The nurse is providing discharge teaching to a client following a total hip 'replacement which of the indicates a proper understanding of discharge instructions E. I cant wait to get home and soak in my bathtub b. It might be hard for me to stay in bed for 3 or 4 days 4.7c. I wont cross my legs when I sit in a char d. I should sleep on the good side for the next 2 weeks 116 A nurse is caring for a client following surgery for open angle glaucoma which of the following should be included in the clients care plan a. position on affected side for sleep b. instill eyedrops with the clients head in a slightly forward position 67. c. instruct client to wear a patch over the affected eye. d. enoucourage use of aspririg for mild discomfort 117. A nurse is instructing an adolescent recently diagnosed with type 1 DM about self blood glucose monitoring which of the following reactions that adolescents should adolescents perform a. provide daily blood glucose level to the primary care provider ub.coorelation of blood glucose with activity • c. keeps a record of blood glucose level • d.modification of insulin regimen to maintain normal glucose level 118. A charge nurse on a cardiac step down unit is receiving a float nurse from a I&D unit which of dr following assignments should the charge nurse give to the float nurse a. a client treated for an episode of bradycardia in the last 8 hours b. a client who is having cliët pain. rated 4 on ascale of Q to 10 c. a client who is 3 days post cardiopulmonary artery bypass surgery d.a client who was admitted for a change in level oriconciousness 119. An older adult client moves in with.her daughter and her family.the daughter tells the visiting nurse that there is a great deal of stress in the family because the father Is interfering with parental decisions, the nurse should take which of the following actions to help integrate the older adult Client into the family structure Osuggest a assistant living arrangement for the client if the problem does no imporove O ask family members to be patient with the client who is adjusting to the new environment E. facilitate a family meeting to discuss and resolve issues related to changes in the family structure F. schedule an.appointment with the primary care provider to rule out physical changes of the clients behavior. 120. A nurse is caring for a client with esoph. Varicies the client is vomiting bright red blood which of the following actions should be taken to protect the client a. obtain the clients BP b. call the emergency response team c. increase the IV flow rate d. suction the oropharynx 121 Which of the following activites should a nurse engage in to assist in disaster prepredness 61. make quarantine preparations for those exposed to anthrox 62. vaccinate susceptible children and adults against small pox A nurse is caring for an adult client with chronic anemia who is to receive a transfusion of 1 unit of packed RBC's which of the following actions is appropriate a.administer the blood via 21 gage intravascular needle b.check clients vitals from previous shift before initiation of trans