ATI Comprehensive C With RATIONALE 100% Graded A

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ATI Comprehensive C 100% Graded A Information you need to pass | 1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription fo... r restraints. Which of the following should the actions 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. Rationale: Verbal orders are those orders given to a licensed physician who is approved by organizational policy to obtain and record verbal orders in compliance with law and regulation by the physician or other providers with prescriptive authority. Bipolar disorder is a mental health condition that induces frequent mood swings that include emotional peaks (mania or hypomania) and lows, previously referred to as manic depression (depression). When you get depressed, you can feel sad or helpless and lose interest or enjoyment in most activities. Therefore, in the case of a client with a bipolar disorder, it is important to document the client's condition 2. A nursing planning care for a school-age child who is 4 hrs. 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 hrs. following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hrs. (for asthma) c. Apply a warm compress to the operative site every 4 hrs. D. ADMINISTER ANALGESICS ON A SCHEDULED BASIS FOR THE FIRST 24 HRS. Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short‑term (24 to 48 hrs.) around‑the‑clock administration of opioids is preferable to following a PRN schedule. ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated on ATI. 3. 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 cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities D. A CLIENT WHO HAS A HIP FRACTURE AND A NEW ONSET OF TACHYPNEA Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR, decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress, tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur after injury usually within 12-48 hrs. 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) b. WEAR GLOVES TO APPLY THE PATCH TO THE CLIENT’S SKIN c. Apply the patch within 1 hr. of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) Rationale https://medlineplus.gov/druginfo/meds/a601084.html: How to apply patch Rationale ATI Skills Module Medication Administration: Topical medications include lotions, creams, ointments, patches, and paste. Because topical medications are absorbed by the skin, wear gloves when applying them to protect yourself against accidental exposure Shaving may cause skin irritation and change the absorption of the drug. 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A CLIENT WHO WAS JUST GIVEN A GLASS OF ORANGE JUICE FOR A LOW BLOOD GLUCOSE LEVEL b. A client who is schedule for a procedure in 1 hr. (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain Rationale Med Surg ATI PDF p529: assess for improvement or worsening of hypoglycemia. Repeat the administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens. 6. 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. 7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an INCREASED in which of the following laboratory values? a. SERUM GLUCOSE LEVEL- INCREASED b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased Rationale ATI MS PDF p518: Cushing disease→ everything is UP except Potassium & Calcium: DECREASED. 8. 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 displaces toxicity. Which of the following actions should the nurse take? P . 235 pharm Ch. 30 a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM D. ADMINISTER CALCIUM GLUCONATE IV Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. 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. Experiencing delusions b. Male gender c. PREVIOUS VIOLENT BEHAVIOR d. A history of being in prison Rationale ATI MH p185: Risk factors also include: history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Rationale ATI COMMUNITY p50: Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. PLACE THE CAP FROM THE SOLUTION STERILE SIDE UP ON CLEAN SURFACE b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level Rationale POTTER & PERRY SKILLS & TECH p187: Remove sterile seal and cap from bottle in upward motion. 11. 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. EAT A LIGHT SNACK BEFORE BEDTIME b. Stay in bed at least 1 hr. if unable to fall asleep c. Take a 1 hr. nap during the day d. Perform exercises prior to bedtime 12. 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. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program C. IDENTIFY ENVIRONMENTAL HAZARDS IN THE HOME d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. 13. 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 tell me who visited you today?” B. “WHAT HIGH SCHOOL DID YOU GRADUATE FROM?” c. “Can you list your current medications?” d. “What did you have for breakfast yesterday?” Rationale ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g. birthdate). OR ask the client to state a fact from their past that is verifiable. Memory of events that occurred in the distant past. 14. 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? P .528 med surg Ch. 82 a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON-COMPLIANT b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC D. HBA1C LEVEL LESS THAN 7% 15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures 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 experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control d. The client is having adverse effects due to combination antimicrobial therapy Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive impairment (http://emedicine.medscape.com/article/816447-clinical#b4 also states that this is an indication of phenytoin toxicity); According to my Davis Drug Guide book, progressive s/s of phenytoin toxicity include ataxia, nystagmus, confusion, nausea, slurred speech & dizziness. 16. 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. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC 17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom 18. 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 might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia 20. 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 let the client know that I am available as the interpreter.” b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m 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.” 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool c, A 2 day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal 22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin 23. 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. Weight gain b. Dry mouth→ anticholinergic effects c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to t 24. 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? P . 177 ch 26 a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths b. The cord stump will fall off in 5 days- about 10 - 14 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry. 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas c. Wheat crackers d. Canned barley soup 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood d. Hypochondriasis ( anxiety disorder) 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the clients legs b. Place a towel roll under the clients neck d. Position a pillow under the client's knees 28. 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. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution 29. A nurse in the 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 → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → 30. 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? CONFIRMED a. Hgb 12.8 g/dl - 12- 16 b. Potassium 4.2 meq/l 3.5 - 5.0 meq c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl (normal: 16-40) c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs 33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? p . 88 ch 13 maternity b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients 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. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 35. 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 ? b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 36. 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? b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. 37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. b. Skin turgor d. Bowel sounds 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 40. A nurse in emergency department is caring for a client who has 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? P. 482 ch 75 CONFIRMED a. Providing pain management b. Offering emotional support c. Preventing infection 41. 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? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. D. Tell her not to worry. She still has plenty of time left. Rationale: Therapeutic communication 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone ! 44. 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? b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? b. 15% c. 8.1% d. 13.3% 46. 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. Perform fundal massage ( massage if fundus is boggy) c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client’s perineal area.( warm) 47. 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? b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. 48. 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? b. Place the client upright on a donut-shaped cushion c. Assess pressure points every 24 hr.- must assess d. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in chair. 49. 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. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress 50. 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. Avocados c. Pepperoni pizza d. Smoked salmon ????? 51. 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. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit (1) b. Activate the facility’s fire alarm system (2) c. Close all nearby windows and doors (3) d. Use the unit’s fire extinguisher to attempt to put out the fire (4) 52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? b. Rapid speech -severe c. Feelings of dread d. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA 54. 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? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds 55. 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 healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) d. Connect abuse survivors with legal counsel (3rd) 56. 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. Administering oral fluids to a client who has dysphagia- d. Reviewing active range-of-motion exercise with a client who had a stroke 57. 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 take sucralfate with meals three times per day” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication- b. Perform chest compressions during cardiac resuscitation- c. Perform a dressing change for a new amputee- d. Apply a transdermal nicotine patch- *60. 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 takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily 61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss d. Hypertension- orthostatic hypotension it will cause instead 62. 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. Asthma c. Fibromyalgia d. Fibrocystic breast condition 63. 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 form? (SATA) e. Cost of the procedure 64. 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? b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? a. Initiate IV fluid replacement- b. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's disease d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? B a. . C and D not shown 68. 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? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion- assess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr d. Administer the blood via a 21-gauge IV needle 69. 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. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: 70. 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 .” b. “I think the baby should be sleeping through the night by now. c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.” 71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? a. Temperature 38 C(100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability c. Pale and 24-hour fluid deficit of 30 mL d. Sunken fontanels and dry mucous membranes 72. 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 partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility a. Ask a student nurse who speaks the same language to translate b. Have the child translate c. Allow the clients partner to translate 73. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? A. Folate level B. INR level C. Vitamin b12 level D. Creatinine level 74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device 75. 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 from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus) c. Uterine atony( fundus not firm which means possible hemorrhage) d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly) 76. A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ? a. Polyuria- oliguria b. Hypotension- hypertension d. Weight loss - weight gain 77. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ? p. 50 ch 7 pharm pdf SSRI for social anxiety , PTSD, B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 78. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? a. your baby will be given 2 ounces of water to drink prior to the test b. this test will be repeated when your baby is 2 months old c. a nurse will draw blood from your baby’s inner elbow d. this test should be performed after you baby is 24 hours old 79. 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 : AVOID Before or AFTER meals b. perform the procedure twice a day c. administer a bronchodilator after the procedure- d. hold hand flat to perform percussions on the child- 80. a nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls→ correct approach; yellow bracelet indicates fall risk b. administering potassium via IV bolus c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication → 81. 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. R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. 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. Take pancrelipase b. Complete oral hygiene c. Eat a meal 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P . 164 ch 27 medsurge b. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usally are up to 4 hours. c. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the procedure , and npo b4 the procedure is uP to 8 hours. d. Place the client in Fowler’s position- supine they must be 84. 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? b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? a. Non maleficence b. Veracity d. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. 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 ? B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. 87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? b. Hyperkalemia- c. Hypercalcemia d. hypoglycemia 88. a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) 140??(not sure) pounds 1 lb per week x 25 week= 25 lbs 75 x 2.2= 165 lbs 165 lbs-25 lbs=140 lbs or 63.6 kg (64 kg) 89. 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 change my baby’s diaper at least every 4 hours b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change Teach the parents to keep the area clean. 90. a home health nurse is caring for an 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. encourage the client to increase fluid intake b. initiate a consultation with a speech→ language pathologist; swallow eval c. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. 1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? a. “You don’t have to go through with the treatment.” b. “Most people who have this procedure feel better following the treatment.” c. “It’s okay to be nervous before this treatment.” d. “Your doctor wouldn’t have ordered this treatment unless it was necessary.” 2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM device. Which of the following actions should the nurse take first? a. Report the defect to the equipment maintenance staff. b. Ensure the device inspection sticker is current c. Remove the device from the room d. Initiate a requisition for a replacement CPM device 3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? a. Document administration of the medication upon removal from the medication dispensing system b. Withhold the medication if the client does not appear to be in pain. c. Count the current number of unit doses available in the medication dispensing system d. Withhold the medication if the client has a fever 4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding? a. Type 2 DM and a blood glucose of 250 mg/dL b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F) c. 2 hr. post cast placement and has 2+ pitting edema and pallor d. First-degree heart block and a heart rate of 62/min 5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. “I will limit my alcohol use to one drink daily while taking disulfiram.” b. “I will avoid foods containing tyramine while taking fluoexetine.” c. “I will take the sustained-release methylphenidate every morning.” d. “I will take my lithium on an empty stomach.” (pharm pg. 64: taking lithium with food will help decrease GI distress) 6. A nurse in the emergency department is assessing client who has major depressive disorder. Which of the following actions should the nurse take first? [View Exhibit] a. Administer Zofran to the client for nausea b. Implement seizure precautions for the client c. Encourage the client to verbalize feelings d. Obtain the client’s weight 7. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder. Which of the following should the nurse expect? a. Suspicious of others b. Exhibits separation anxiety c. Ritualistic behavior d. Preoccupied with aging 8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein per day should the nurse include in the client’s dietary plan? 9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following actions should the nurse take first to manage her time effectively? a. Develop an hourly time frame for tasks b. Schedule daily activities c. Determine goals of the day d. Delegate tasks to the AP 10. 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. Measure the client’s urine output every hour c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium gluconate) d. Monitor the FHR via Doppler every 30 min 11. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? a. Infected laceration b. Stage II pressure ulcer c. Approximated surgical incision d. Partial-thickness burn 12. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. Client taking clozapine to treat schizophrenia and reports sore throat (pharm pg. 72: monitor for infection [fever, sore throat, etc.]) b. Client has OCD and is upset about a change in daily routine c. Client has narcissistic personality disorder and is mocking others during group therapy d. Client who has depressive disorder and requires assistance with ADLs 13. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to assess the port? a. An angiocatheter b. A butterfly needle c. A noncoring needle d. A 25 gauge needle 14. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test? a. PT and INR b. 12 lead ECG c. Chest X-ray d. Serum potassium 15. A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions should the nurse ask the parent to determine if the child is exhibiting typical developmental expectations? a. “Can your child draw a stick figure?” b. “Can your child catch and throw a small ball?” c. “Can your child ride a tricycle?” d. “Can your child name five colors?” 16. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Measure the fundal height to determine the placement of the ultrasound stethoscope b. Perform Leopold maneuvers prior to auscultating the FHR c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR d. Place the client in a side-lying position prior to assessing the FHR 17. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. There is a loop of tubing below the drainage system b. The system is working properly (medsurg pg. 104: tidaling in the water seal chamber and continuous bubbling only in the suction chamber) c. The lung has re-expanded d. The tubing is partially obstructed by clots 18. 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 is receiving heparin for DVT b. A client who is 1 day postoperative following a vertebroplasty c. A client who has COPD and a respiratory rate of 44/min d. A client who has cancer with a sealed implant for radiation therapy 19. A nurse is caring for a client who has ESRD. 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. Osteoarthritis b. HTN c. Amputation d. Primary glaucoma 20. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (SATA) a. Foul perineal odor b. Fundus displaced to the right c. Lochia serosa d. Fundus 4 cm (1.6 in) below the umbilicus e. Postpartum chill 21. 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. Hold hand to perform percussions on the child c. Administer a bronchodilator after the procedure d. Perform the procedure prior to meals 22. A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following action should the nurse take? a. Ensure that the client checks the gauge weekly b. Store the oxygen tank wrench in a locked cabinet c. Have the client store smaller tanks under his bed d. Place the oxygen tank away from curtains or drapes 23. Location of crackles [IMAGE] 24. A nurse is caring for a newly client who has bacterial meningitis. Which of the following actions should the nurse take? (medsurg pg. 31) a. Implement seizure precautions b. Place the client in high-Fowler’s position c. Perform ROM exercises once per shift d. Monitor the client for hypoglycemia 25. A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? a. Na 142 mEq/L b. Blood glucose 80 mg/dL c. K 3.3 mEq/L d. PT 11.5 seconds 26. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? a. Reset the vacuum by compressing the container b. Secure the drain to the bedding c. Position the affected extremity below the level of the client’s heart d. Maintain the client in a supine position for the first 24 hr. 27. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse assess first? a. DM and HbA1c of 5.2% b. Leukemia and platelet level of 95,000/mm3 c. Received IV Lasix and K of 3.6 mEq/L d. Hepatitis B and total bilirubin of 1.2 mg/dL 28. A nurse is developing plan of care for a newborn mother tested positive for heroin during pregnancy. Newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Minimize noise in the newborn’s environment b. Swaddle the newborn with his legs extended c. Administer naloxone to the newborn d. Maintain eye contact with the newborn during feedings 29. Nutritional teaching for an adult client who has seizure disorder and a new prescription for phenytoin. Which of the following instructions by the nurse is appropriate? a. “You should expect a change in the color of your stool while taking this medication.” b. “Increase your intake of vitamin D while taking this medication.” (pharm pg. 96: consume adequate amounts of calcium and vitamin D) c. “Plan to take this medication with antacids.” d. “Limit foods that contain folic acid while taking this medication.” 30. A nurse is assessing a client who presents to the L&D unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? a. Presence of bloody show b. Contraction intensity increased by ambulation c. Slow change in dilation and effacement d. Intermittent, painless contractions 31. A nurse is caring for a client who has Cdif. Which of the following actions should the nurse take? (SATA) a. Wash hands with alcohol based b. Wear N95 c. Remove thermometer from client’s room for use on another client d. Change gloves after contact with infectious material e. Wear a gown when providing care 32. 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. DM and HbA1C of 6.8% b. Hip fracture and a new onset of tachypnea c. Epidural analgesia and weakness in lower extremities d. Sinus arrhythmia and is receiving cardiac monitoring 33. Nurse accidently punctures IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a bio hazardous material spill? a. Phenytoin b. Doxorubicin hydrochloride c. Metronidazole d. Ampicillin sodium 34. Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication? a. Respiratory rate 22/min b. Hgb 8.7 g/dL c. 2+ pitting edema of the ankles d. Creatinine 2.3 mg/dL (pharm pg. 365: nephrotoxicity) 35. Which of the following clients should the nurse recommend referral to a dietitian? a. Older adult who has BMI of 24 b. Client with albumin of 3.7 g/dL c. Older adult who has presbyopia d. Client who has a nonhealing leg ulcer 36. Support group for clients whose family have committed suicide. Which of the following should the nurse plan to use during the group session? a. Encourage clients to establish a timeline for their grieving process b. Assist clients in identifying ways suicide could have been prevented c. Discourage clients from sharing negative aspects of their relationship with the deceased persons d. Initiate a discussion with clients about ways to cope with changes in family dynamics 37. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. A history of being in prison c. Male gender d. Previous violent behavior 38. Arial fibrillation places the client at risk for which of the following conditions? a. Pulmonary emboli b. Cardiac tamponade c. Widened pulse pressure d. Hemothorax 39. Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan? a. Refer to the hallucinations as if they are real b. Encourage the client to lie down in a quiet room c. Ask the client directly what he is hearing d. Avoid eye contact with the client 40. Circumcised newborn. Which of the following instructions should the nurse include in the teaching? a. “Wrap sterile gauze around the penis if bleeding occurs.” b. “Use soap to cleanse the site.” c. “Apply petroleum jelly to the glans with diaper changes.” d. “Remove yellow exudate around the penis.” 41. Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? a. Schilling test (medsurg pg. 254) b. Oral glucose tolerance test c. D-dimer test d. Thyroid scan 42. A nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? a. Administer atropine to the client if tachycardia is present b. Maintain the indwelling urinary catheter until the client is ready for discharge c. Prepare for fluid volume replacement if the central venous pressure steadily increases d. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr (medsurg pg. 185: volume exceeding 150 mL/hr could be a sign of hemorrhage) 43. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing? a. Morphine b. Digoxin c. Prednisone d. Omeprazole 44. Client becomes unconscious and monitor displays v-tach. Which action should the nurse take first after determining the client does not have a palpable pulse? a. Establish IV access b. Administer epinephrine c. Defibrillate d. Assess heart sounds 45. A nurse is caring for several clients on a med surg unit. For which of the following nursing activities is it required that the nurse use sterile gloves? a. Initiating IV assess b. Performing tracheostomy care c. Inserting an NG tube d. Administering total parenteral nutrition through a central venous assess device 46. Lab results s/p surgery. Which should be reported to the provider? a. Na 160 mEq/L b. Cl 100 mEq/L c. Bicarbonate 26 mEq/L d. K 3.8 mEq/L 47. Nurse is developing care plan for client on Buck’s traction and is schedules for surgery for a fractured femur of the right leg. Which should the nurse delegate to an AP? a. Observe the position of the suspended weight b. Remind the client to use the incentive spirometer c. Check the client’s pedal pulse on the right leg d. Ask client to describe her pain 48. Client in ER experiencing stimulant withdrawal. Which finding should the nurse expect? a. Decreased appetite b. Runny nose c. Muscle spasms d. Fatigue 49. Postpartum client with a language barrier. Which of the following actions should the nurse take to gather the client’s admission data? a. Allow client’s partner to translate b. Request female interpreter through the facility c. Have client’s child translate d. Ask nursing student who speaks the same language as the client to translate 50. Operating fire extinguisher [arrange] 1) Unlock the handle by pulling on the pin 2) Point the hose at the base of the fire 3) Squeeze the handle by pulling on the pin 4) Sweep the extinguisher from side to side 51. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy obtain a copy of the therapist’s notes. Which of the following responses should the nurse make? a. “Are you not happy with your treatment?” b. “Why are you interested in seeing your therapist’s notes?” c. “I don’t think you will benefit from reviewing your therapist’s notes right now.” d. “We can provide a copy of your records, but the therapist’s notes are not included.” 52. A nurse is assessing a client who has hypervolemia. Which of the findings should the nurse expect? a. Urinary frequency b. Decreased BP c. Bounding pulse (medsurg pg. 267) d. Bradycardia 53. Inserting indwelling urinary catheter to a male client. Which of the following actions should the nurse take? a. Cleanse the tip of the penis in a side to side motion b. Pick up the catheter 13 cm (5 in) from its tip c. Perform the cleansing procedure with a fresh swab two times d. Lift the penis so that it is perpendicular to the client’s body 54. A nurse is caring for a client who is febrile. To reduce fever, the nurse applies a cooling blanket. Which of the findings indicates the client is having an adverse reaction to the cooling? a. Tachycardia b. Flushing c. Shivering d. Restlessness 55. Teaching for misoprostol. Which information should be included in the teaching? a. “You will have a urinary catheter inserted prior to the placement of the medication.” b. “You will lie on your side for 30 min after the medication is inserted.” c. “You will have oxytocin initiated within 3 hours of administration of the medication.” d. “You will have intermittent fetal monitoring while you receive the medication.” 56. Client in psychiatric unit. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? a. “That can’t be true. The only voices in this room are yours and mine.” b. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” c. “I understand the voices are frightening you, but I do not hear any voices.” d. “DO YOU RECOGNIZE THE VOICES AS BELONGING TO ANYONE YOU KNOW?” 57. Teaching the parent of an infant who has positional plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? a. “I should place my baby in the left side-lying position at night when using the helmet.” b. “I should avoid tummy time when my baby is wearing the helmet.” c. “I should expect to have my baby wear this helmet for 10 months.” d. “I should keep the helmet on my baby for 23 hours a day.” 58. Which of the following lab findings should the nurse recognize as indicative of rheumatic fever? a. Decreased hgb and platelet count b. Decreased myoglobin and antinuclear antibody titer c. Elevated sedimentation rate and C-reactive protein d. Elevated creatine kinase and troponin 59. Client with pneumonia gained 4.2 (9.3 lb.) over the last 5 days. Lab values this morning are: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? a. Nephrologist b. Cardiologist c. Infectious control nurse d. Dietitian 60. A nurse received change of shift report. Which of the following actions should the nurse take to manage time effectively? a. Focus on several client tasks at a time b. Document client care at the end of the shift c. Skip breaks until client tasks are completed d. Make a client to-do list for the day 61. Protocols for belt restraints. Which of the following guidelines should the nurse include? a. Remove the client’s restraint every 4 hr. b. Request a PRN restraint prescription for clients who are aggressive c. Attach the restraint to the bed’s side rails d. Document the client’s condition every 15 min 62. Assessing client in ER. Which of the following actions should the nurse take first? [View Exhibit] a. Obtain ABG levels b. Elevate the head of the client’s bed to 30° c. Place client on a coating blanket d. Administer an analgesic 63. Client who has depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicators an understanding of the teaching? a. “I can continue to take St. John’s wort while taking this medication.” b. “I know it will be a couple of weeks before the medication helps me feel better.” (pharm pg. 56: it can take 10-14 days or longer) c. “I expect this medication to raise my blood pressure.” d. “I should take this medication on an empty stomach.” 64. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing b. Sit at or below the client’s eye level during feedings c. Talk with the client during her feeding d. Discourage the client from coughing during feedings 65. Child with sickle cell anemia. The nurse should emphasize the importance of which of the following factors to prevent sickle cell crisis? a. A low-protein diet b. ADEQUATE HYDRATION c. Calorie restriction d. Increased iron intake 66. Client with indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? a. PROVIDE PERINEAL HYGIENE AFTER DEFECATION b. Empty the collected urine once every 24 hr. c. Hang the drainage bag on a bed rail d. Change the indwelling catheter every 8 hr. 67. Client experiencing acute mania. Which of the foods should the nurse provide for this client? a. Peanut butter sandwich b. Chicken noodle soup c. Celery sticks d. Oatmeal with butter 68. ?????????? 69. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? a. Client who reports being given sedative medications by family members b. Client who is taking warfarin and has several small bruises on her shins and hands c. Client who schedules multiple visits with his provider every month d. Client who lives with family members and begins to take more responsibility for self-care 70. A nurse is caring for a school age child who is postoperative and received morphine IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority? a. Bradypnea b. Sedation c. Euphoria d. Constipation 71. A nurse is planning to administer 2 units of packed RBCs to an older adult who has anemia. Which of the following actions should the nurse plan to take? [SATA] (medsurg pg. 249) a. Prime the infusion tubing with 0.45 NaCl b. Infuse blood over 4 hr. c. Don sterile gloves to prepare blood administration setup d. Assess the client’s lung sounds prior to the infusion e. Verify with another nurse that the unit of blood is compatible with the client’s blood type 72. A nurse is planning care for a client who is scheduled to receive a PICC in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? (medsurg pg. 166) a. Administer sedation for the procedure b. Measure the arm circumference above the insertion site daily c. Use gauze to secure an arm board to the involved extremity d. Schedule and MRI postprocedure to verify placement 73. Which of the following clients should the nurse place near the nurses’ station? a. A client who is in Buck’s traction b. A client who has orthostatic hypotension c. A client who has an open wound d. A client who is on fluid restriction 74. Older client transferred from another facility. Nurse notes ulcers on the coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? a. Notify risk management b. Inform the transferring agency of the client’s condition c. Privately interview the client about her condition d. Contact the family regarding the client’s condition 75. Client receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. History of GERD b. Sitting in a high-Fowler’s position during the feeding c. A residual of 65 mL 1 hr. postprandial d. Receiving a high osmolarity formula 76. Adverse effects of sertraline a. Dry cough b. Increased urinary frequency c. Metallic taste in mouth d. Excessive sweating (pharm pg. 53: serotonin syndrome) 77. Teaching for a client undergoing radiation therapy and has stomatitis. Which of the responses by the client indicates an understanding of the teaching? a. “I should limit my intake of dairy products to prevent nausea.” b. “I should use a soft-bristle toothbrush to clean my teeth after meals.” c. “I should moisten my lips with lemon-glycerin swabs.” d. “I should gargle with an alcohol-based mouthwash to kill germs.” 78. Client placed in seclusion and restraints. Which of the following actions should the nurse plan to take? a. Ensure that the prescription for restraints be renewed every 6 hr. b. Have a provider evaluate the client in person within 1 hr. c. Plan to monitor the client every 30 min while restrained d. Complete a written record regarding the seclusion and restraint every 2 hr. 79. Client with acute glomerulonephritis. Which of the following food choices should the nurse recommend? (low in potassium, sodium, and protein) a. Bagel b. Banana c. Eggs d. Smoked salmon 80. Client asks about acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. HTN b. Herpes zoster c. Obesity d. Hypothyroidism 81. Reviewing client’s lab results. Which of the following should the nurse review to evaluate the client’s nutritional status? a. Serum albumin b. Serum sodium c. Troponin d. ESR 82. Nurse manger observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following should the nurse manager take first? a. Request the nurses present an in-service on client confidentiality b. Place documentation of the nurses’ actions in the personnel file c. Instruct the nurses to close the client’s computer record d. Advise the nurses to read the facility’s confidentiality policy 83. Discharge teaching to a client who does not speak the same language as the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? a. Use gestures to convey meaning b. Speak slowly when talking to the interpreter c. Speak directly to the client d. Pause in the middle of the sentences 84. Teaching the parents of a client with new onset of seizures and is to undergo an EEG. Which of the following instructions should the nurse include in the teaching? a. “Ensure the child’s hair is clean and without conditioner before the procedure.” (medsurg pg. 18: instruct client to wash his hair prior to the procedure and eliminate all oils, gels, and sprays) b. “Keep the child out of the sun for 4 hr. following the procedure.” c. “Make the child NPO before the procedure.” d. “Give the child acetaminophen for pain following the procedure.” 85. Client presented with fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? a. Hyperthyroidism b. Hyperparathyroidism c. Hypothyroidism d. Hypoparathyroidism 86. Client on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? a. Decreased serum calcium levels b. Increased BP c. Urinary frequency d. Swollen area on calf 87. A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? (medsurg pg. 164) a. Administer nitroglycerin 0.4 mg SL 30 min before the procedure b. Draw blood specimens for culture and sensitivity c. Transport the client to radiology for a CT scan d. Obtain CBC with differential 88. 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. “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. “This test will be repeated when your baby is 2 months old.” d. “Your baby will be given 2 ounces of water to drink prior to the test.” 89. New prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? a. “Take with a protein shake.” b. “Report dark-colored urine.” c. “Monitor for hyperglycemia.” d. “Change positions slowly.” (pharm pg. 93: orthostatic hypotension) 90. Identify ECG [IMAGE] of client with potassium toxicity 91. A nurse is caring for a client who is insulin dependent and is undergoing tests 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. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% 92. 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. Blood pressure C. Respiratory rate D. aPTT 93. 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 the client to use jet therapy on her lower back for 1 hr B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen C. Using effleurage on a client’s lower abdomen D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30 min 94. 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. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 D. Evaluate the APs’ performance of each task 4 95. 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 a virus.” B. “I should wash my hands for 10 seconds with hot water after working in the garden.” C. “I can clean my cat’s litter box during my pregnancy.” D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 96. A nurse I 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 intermittent pressure 2.5 cm (1 in) below the percutaneous skin site. B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site. C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site. D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. 97. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? A. Phlebitis B. Abdominal aortic aneurysm C. Osteoarthritis D. Peripheral neuropathy 98. 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. Sensation of skin warmth B. Headache C. Increased salivation D. Numbness and tingling of the extremities 99. 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. Lorazepam .5 mg PO one tablet daily B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 100. 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. Swelling of the face B. Urinary frequency C. Faintness upon rising D. Bleeding gums 101. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 D. Xerostomia 102. A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus 103. 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 last 30-60 sec” D. “This type of seizure has a gradual onset” 104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use B. Tape stockinet over monitoring device and cords C. Schedule the client as the last surgery of the day D. Remove poopsocks from the IV 105. A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication. A Dumping syndrome B Ketoacidosis C Hepatotoxicity D Thyroid storm 106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft from the client E. Close the door to the client's room 107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem 108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one B. Move your son to a toddler bed when the baby arrives C. Tell your son to kiss the baby D. Teach your son to change the baby diapers - not the answer 109. A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics- C. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen D. Bounding pulse 111. 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. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occur. . 112. 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 113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. b. Request non gas forming foods from the dietary department c. Limit the client’s food consumption between meals. d. Arrange for a low protein diet. HIGH PROTEIN. 114. 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 infectious disease that should be reported to the state health department? a. Candidiasis b. Herpes simplex virus c. Human papillomavirus d. CHLAMYDIA 115. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, 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. Place a cardiac monitor on the client b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hr urine collection . 116. 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. -Avoid vigorous activities. b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds. c. I can resume activities, such as sewing. d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level. 117. 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. Give the dose over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose 118. 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 -not for pts with CKD or dialysis. b. Eat 1g/kg of protein per day c. Drink at least 3L of fluid daily -too much fluid d. Consume foods high in potassium -low potassium diet 119. A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology- b. Take the vital signs of the clients on the side of the unit c. TELL ME THE STANDING WEIGHT OF THE CLIENT IN ROOM 102 BEFORE BREAKFAST d. The client in room 109 has spilled his water pitcher Rationale: right direction/communication. Leadership. 120. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site b. Blood pressure 92/68 mm Hg - c. Urine output 35mL/hr d. Pedal pulse of +1 bilaterally 121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward . 122. 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. Hop on one foot B. Kick a ball forward C. Climb Stairs with alternate feet D. Ride a tricycle 123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. Im sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. ● Facilitating conti ● Improving efficiency of care and utilization of resources 124. A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures 125. 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 effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. B. Check the client's serum albumin levels C. Examine for leakage at thes site of the procedure D. Confirm that the client is able to urinate 126. 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. Swaddle the newborn with this leg extended. B. Maintain eye contact with the newborn during feedings. C. Minimize noise in the newborn environment D. Administer naloxone to the newborn ● Reduce environmental stimuli (decrease lights, lower noise level). 127. 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. PARTICIPATE IN COMMUNITY DRILLS AND MOCK EVENTS. B. Vaccinate susceptible children and adults against smallpox C. Assess types, levels and scopes of disasters. D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First 128. A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect? A. Ritualistic behavior (OCD) B. Exhibits separation anxiety (Dependent) C. Preoccupied with aging D. Suspicious of others. (Paranoid) 129. 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. Withdraw the client's TV privileges if he does not attend group therapy B. Place the client in seclusion when exhibits signs of anxiety C. Encourage the client to take frequent rest periods. D. Encourage the client to spend time in the day room 130. A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. (Stage IV Kidney Disease) B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. 131. A nurse is auscultating heart sounds of an 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 findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area 132. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet ● People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato 133. 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. Seizure disorder b. Polycystic ovary syndrome c. Renal insufficiency d. Gluten intolerance 134. 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. Vomiting c. Hypertension d. Epigastric pain -google 135. 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 who is 6 hr postop following a herniorrhaphy and reports pain at the IV site b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120 c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate 136. 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 alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after i first feel the urge to urinate 137. 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 SHOULD URINATE BEFORE THE TEST c. I will lie on my left side during the test d. I will drink an oral glucose solution during the test 138. 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. Memory loss b. Slurred speech c. Elevated temperature d. hypotension ● Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension 139. 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. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules 140. 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. Consume food high in bran fiber c. Sweeten foods with fructose corn syrup d. Increase intake of milk product ● Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids 141.A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client’s condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client’s condition. 142.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. Maintain NPO status for client(ABC) b. Change client's position every 2 hours c. Perform range-of-motion exercises to client’s extremities. d. Place the clients right hand in supination position. 143. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 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 protein intake during the third trimester”( increase protein for basic growth) b. “I will need to increase my insulin doses later in my pregnancy” c. “I will increase my carbs at breakfast and limit them the rest of the day” d. “I will decrease my calorie consumption during the first trimester”(increase calorie) 144.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. Test the client for Trousseau’s sign b. Assess the client’s skin turgor c. Check the client’s motor strength d. Measure the client’s pupil size 145. 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 clean my stoma with warm water”( can use low ph soap and water) b. “ My stoma should be bright pink or red”(pink,red and moist) c. “I should change the stoma pouch every day” d. “I should cut my pouch opening ⅛ inch larger than my stoma”(allow expansion) Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. 146.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. Hyporeflexia b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hr) 147.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 148.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. “I cannot be a witness for your consent to donate” c. “You must be at least 21 years of age to become an organ donor” d. “Your name cannot be removed once you are listed on the organ donor list 149.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr 150.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen 151. 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. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension 152. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. THE CLIENT EXHIBITS IMPULSIVE BEHAVIOR. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic 153. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension Rationale: 154. 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 affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure. 155. 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 client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. 156. 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. “You can add the medication to a half-cup of your child’s favorite juice.” B. “Repeat the dose if your child vomits within 1 hour after taking the medication.” C. “Limit your child’s potassium intake while she is taking this medication.” D. “Have your child drink a small glass of water after swallowing the medication.” 157. 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. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension 158. 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 treatment. C. A client who is 1 day postoperative following a vertebroplasty D. A client who is receiving heparin for deep vein thrombosis. 159. 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. Fasting blood glucose 108 mg/dl (WNL) B. WBC 9,800/mm (WNL) C. Creatinine 0.9 mg/dl (WNL) D. Potassium 5.2 mEq/L . 160. 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? Paul for 158 would u pick D ? A. Engage the client in activities that increase sensory stimulation. B. Discourage physical activity during the day. C. Establish a toileting schedule for the client. D. Use clothing with buttons and zippers. 151. 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. Orthostatic hypotension - b. Dependant Edema- fluid volume excess c. Decreased Hematocrit - fluid volume excess d/t super diltion d. Neck vein distention - fluid volume excess 152. 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 overly concerned about minor details c. The client is exceptionally clingy to others d. The client might act seductively 153. A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ? a. 3+ deep tendon reflexes -preeclampsia b. Protruding hemorrhoids c. Urinary frequency ch 4 p. 21 maternal- d. Supine hypotension - teach them side lying position 154. 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. Inform the provider of the time of the last does of pain medication b. Document the sequence of events as they occur c. Provide non pharmacological pain management interventions d. Instruct the client about the steps of the procedure 155. 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 client was intubated without complication c. There was a total of 10 sponges used during the procedure - what kind d. The client is a member of the board of directors 157. A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension 158. A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge ? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range b. A client who has cancer with a sealed implant for radiation therapy - an implant is inside them, and its active c. A client who is 1 day postoperative following a vertebroplasty d. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for Hospital and that other Coumadin for home 159. A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery ? a. Fasting blood glucose 108 mg/ dl b. WBC 9,800 mm3 > 4,800 is normal c. Creatnine 0.9 mg/dl , < 1.0 is normal d. Potaissium 5.2 meq / L 3.5 - 5.0 = 160. 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. Engage the client in activities that increase sensory stimulation. b. Discourage physical activity during the day c. Establish a toileting schedule for the client d. Use clothing with buttons and zippers 161. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred Assess the situation first prior to trying to solve it. 162. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. 163. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding - not without crushing them first b. Dissolve the medications together- some medications can mix others can’t c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water- 10ml 164. The 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 165. A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. I can use my ultrasound picture as a focal point during contractions 166. A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute - wnr c. 2 PVCs per minute d. Widened P wave 167. 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. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Increases the tpn infusion rate each hour until the prescribed rate is achieved 168. 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. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your responsibility to contain it b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - no comparison 169. A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations -either or is fine b. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the right way c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear d. Count respirations for 1 minute if the rhythm is irregular 170. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff c. contact the laboratory manager regarding the situation - you are not high enough up the chain to do that d. Notify the facilities legal department - no need to go that far 171. A nurse is assessing a client who requests 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 infections d. Migraines with aura Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease. 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 pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache 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. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hr prior to the procedure. . A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia b. Chorioamnionitis c. Fetal anemia d. Maternal fever 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 therapeutic? a. “You should make sure your partner takes the prescribed medication.” b. “Why do you think your partner’s symptoms are progressing so quickly?” c. “You did the right thing by bringing your partner in for treatment.” d. “Can you talk about what was happening with your partner at home?” 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 potassium c. Liver function test d. Serum creatinine A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” b. “The PCA will deliver a double dose of medication when you push the button twice.” c. “You should push the button before physical activity to allow maximum pain control.” d. “You can adjust the amount of pain medication you receive by pushing on the keypad.” 178. 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. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure. 179. 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. Potassium 3.2 mEq/L 3.5 - 5.0 is normal b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL 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.”- 91. Client in postpartum taking methylergonovine. The nurse should recognize that which of the following is a contraindication for this medication? a. HTN (pharm pg. 253: contraindications/precautions) b. Polyuria c. Confusion d. Chlamydia 92. Parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching? a. Position the nipple at the front of the infant’s mouth b. Burp the infant frequently during feedings (peds pg. 139) c. Use feeding devices without nipples d. Hold the infant in a supine position 93. Client with Alzheimer’s disease. Which of the following should the nurse include in the plan of care? a. Encourage physical activity prior to bedtime b. Replace the carpet with hardwood floors c. Wear clothing with zippers instead of buttons d. Place locks at the top of exterior doors (medsurg pg. 46: installing door locks that cannot be easily opened) 94. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Acrocyanosis b. Bulging fontanels c. Bradycardia d. Hypertonicity 95. A newly LPN working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Using an electronic massaging system to remind clients when to take medications b. Educating clients about contraindications to specific immunizations c. Helping clients understand health screenings covered by their insurance plans d. Providing clients with info about the benefits of exercise 96. Client who has bipolar disorder and is experiencing mania. Which of the following 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 (mental pg. 76: seclusion might be the only way to safely decrease stimulation) d. Withdraw the client’s TV privileges if he does not attend group therapy 97. A nurse in the ER is receiving report for four clients. Which should the nurse see first? a. Client who has HTN and reports severe headache (stroke) b. Client who reports left arm pain following a fall c. Client who has heart failure and received diuretic 30 min ago d. Client who reports frequent and painful urination 98. A nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide? a. “Respite care provides clinicians to work with you in caring for your husband.” b. “Respite care allows for time away from caring for your husband.” c. “Respite care includes volunteers who will perform household tasks.” d. “Respite care offers financial resources to help care for your husband.” 99. Education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? a. Fibrocystic breast disease b. Fibromyalgia c. Renal calculi d. HTN (pharm pg. 246: use cautiously in clients who have hypertension) 100. Admitting a client who is in labor and at 38 weeks of gestation. The client has a history of herpes simplex virus 2. Which of the following questions is most important for the nurse to ask the client? a. “Are you currently taking acyclovir?” b. “Do you have an active lesion?” c. “When did your labor begin?” d. “How long ago were you first diagnosed?” 101. 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 NG tube clamped after administering oral medication b. Administering potassium via IV bolus c. Documenting communication with a provider in the progress notes of client’s medical record d. Placing a yellow bracelet on a client who is at risk for falls 102. Lab results of a client who has osteomyelitis and is receiving tobramycin. Which of the following findings indicate the client is experiencing an adverse effect of the medication? a. Serum creatinine 0.4 mg/dL b. Albumin 3.2 g/dL c. Total bilirubin 0.08 mg/dL d. BUN 30 mg/dL 103. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Zinc b. Calcium c. FOLATE d. Iron 104. The nurse practices the ethical principles of distributive justice by performing which of the following? a. Ensuring that a client who is homeless receives preventive medical care b. Being honest with the parents of a child about the need to report suspected abuse c. Keeping a promise to visit with a client who is housebound after the delivery of care d. Accepting the decision of an older adult client to live alone in her home 105. Client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care? a. OBSERVE FOR BRUISING OF THE SKIN b. Provide a diet low in protein c. Monitor v/s every hour for the first 4 hr. d. Administer medications intramuscularly 106. Client with dementia. Which of the following actions should the nurse take to reduce the risk for client injury? a. Keep the television on during the night b. Place the bedside table at the foot of the bed c. Raise the side rails up when the client is in bed d. Assist the client to the toilet frequently 107. Assessment of an 8 y/o child. Which of the following findings indicates the need for intervention by the nurse? a. Client eats at least one snack daily b. Client’s weight has increased by 0.9 kg (2 lb.) c. Client’s height has increased by 6.35 cm (2.5 in) d. Client drinks 3 cups of 1% milk per day 108. Client following thyroidectomy. For which of the following complications should the nurse assess the client? a. Muscular depression b. Laryngeal stridor c. Hypokalemia d. Hyperglycemia 109. Teaching to a client who is at 12 weeks gestation. The nurse should tell the client that she will undergo which of the following screening tests at 16 weeks of gestation? a. Maternal serum alpha-fetoprotein b. Chorionic villus sampling c. Cervical cultures for chlamydia d. Nonstress test 110. A certified IV nurse is providing education about PICC to a newly LPN. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (medsurg pg. 166) a. “Position the client’s arm in adduction for PICC placement.” b. “Informed consent is required prior to PICC placement.” c. “Use a vein in the middle of the lower arm to insert a PICC.” d. “Flush a PICC using a 3 mL syringe.” 111. Which of the following clients should the nurse refer for speech therapy? a. Client who has dysphagia following a stroke b. Older adult client who has stage III Alzheimer’s disease c. Client who has sensorineural hearing loss d. Client who is postoperative following a tonsillectomy and adenoidectomy 112. Teaching a client who is 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching? a. “You should avoid eating or drinking for 4 hours before the test.” b. “You should massage one of your nipples to stimulate contractions of your uterus.” c. “You will need blood work before and after the test.” d. “You will have a Doppler transducer applied to your abdomen during the test.” 113. Management of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Respiratory therapist c. Speech-language pathologist d. Occupational therapist 114. A nurse is developing an in-service about personality disorders. Which of the following should the nurse include when discussing borderline personality disorder? a. “The client might act seductively.” b. “The client is exceptionally clingy to others.” c. “The client exhibits impulsive behavior.” (mental pg. 85: compulsiveness and lack of social restraint) d. “The client is overly concerned about minor details.” 115. Client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching? a. “I will floss between my teeth every time I brush.” b. “I will use an enema to manage my constipation.” c. “I will remove my shoes when I’m inside my house.” d. “I will wipe my nose instead of blowing it.” 116. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Contact the family by phone c. Schedule a time for the home visit d. Implement the nursing process 117. Discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications? a. Ranitidine b. Vitamin B12 c. Metoclopramide d. Vitamin K 118. A nurse is providing an in-service about client evacuation during a afire. Which of the following clients should the nurse instruct the staff to evacuate first? a. Client who is bedridden and wears a hearing aid b. Client who has a fracture and is in balance suspension traction c. Client who is ambulatory and receiving oxygen d. Client uses a wheelchair and is confused 119. 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. “Have your child drink a small glass of water after swallowing the medication.” b. “Repeat the dose if your child vomits within 1 hour after taking the medication.” c. “You can add the medication to a half-cup of your child’s favorite juice.” d. “Limit your child’s potassium intake while she is taking this medication.” 120. A nurse is providing discharge teaching to a client who has CKD and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? (medsurg pg. 382: “at least 2 L water daily; control protein; restrict sodium, potassium, phosphorous, and magnesium”) a. Consume foods high in potassium b. Eat 1 g/kg of protein per day c. Drink at least 3 L of fluid daily d. Take magnesium hydroxide for indigestion 121. Client who is 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Epigastric pain b. Vomiting c. HTN d. Contractions (OB pg. 34: advise the client to report to her provider if she experiences fever, chills, leakage of fluid, bleeding from insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure) 122. Preoperative assessment for a client allergic to several foods. Which of the following food allergies indicates a risk factor for latex allergy? a. Eggs b. Peanuts c. Shrimp d. Bananas 123. Assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? a. Both fontanels show molding b. Both fontanels are the same size c. The posterior fontanel is open (closes at 2-3 months) d. The anterior fontanel is open (closes at 18 months) 124. Parents of an infant who has tracheostomy. Which of the following instructions should the nurse include in the teaching? a. “Apply suction for 30 seconds after advancing the catheter.” b. “Set the suction machine to 60 mm Hg.” c. “Instill 2 mL of saline in the tracheostomy prior to suctioning.” d. “Advance the suction catheter just past the point of resistance.” 125. Client asks info regarding organ donation. Which of the following responses should the nurse make? a. “Your name cannot be removed once you are listed on the organ donor list.” b. “I cannot be a witness for your consent to donate.” c. “You must be at least 21 years of age to become an organ donor.” d. “Your desire to be an organ donor must be documented in writing.” 126. Client following abdominal surgery. Which of the following findings should the nurse report to the provider? a. BP 100/70 mm Hg b. Serous drainage on the abdominal dressing c. Temperature 37.6° C (99.7°F) d. Urinary output 20 mL/hr. 127. A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take? a. Assist the adolescent in applying for Medicaid b. Refer the adolescent to a local mental health clinic c. Contact the adolescent’s parent for assistance d. Advise the adolescent to lace the newborn for adoption 128. Client with acute angle-closure glaucoma. Which of the following findings should the nurse expect? (medsurg pg. 66: s/s – elevated IOP; decreased/blurred vision; colored halos; pupils nonreactive to light; severe pain and nausea; photophobia) a. Reddened cornea b. Severe periocular pain c. Gray cast to sclera d. Increased light perception 129. Client who is 11 weeks gestation. Which of the immunizations should the nurse recommend? a. Varicella b. Influenza c. Human papillomavirus d. MMR 130. The nurse should identify that which of the following client findings requires follow up care? a. Client who is taking bumetanide and has a potassium level of 3.6 mEq/L b. Client who is taking warfarin and has an INR of 1.8 c. Client who received Mantoux test 48 hr. and has an induration d. Client who is scheduled for a colonoscopy and is taking sodium phosphate 131. Assessment of client in active labor. Which of the following findings should the nurse report to the provider? a. FHR baseline 170/min b. Contractions lasting 80 seconds c. Temperature 37.4° C (99.3° F) d. Early decelerations in the FHR 132. Client who has DVT of the left lower extremity. Which of the following actions should the nurse take? [View Exhibit] a. Massage the affected extremity every 4 hr. b. Position the client with the affected extremity lower than the heart c. Administer acetaminophen d. Withhold heparin IV infusion 133. 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 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 wash my hands for 10 seconds with hot water after working in the garden.” d. “I should take antibiotics when I have a virus.” 134. Discharge teaching for metoprolol. Which of the following should the nurse instruct the client to monitor and report to the provider? a. Polyuria b. Bradycardia c. Tinnitus d. Hyperglycemia 135. The nurse should recognize that which of the following clients is at greatest risk for developing acute poststreptococcal glomerulonephritis? a. 18 y/o girl who is in the second trimester of pregnancy b. 7 y/o boy who is recovering from impetigo c. 2 month old girl who has pyloric stenosis d. 16 y/o boy who has appendicitis 136. Teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching? a. “Biofeedback stimulates certain pressure points to relax muscles.” b. “Biofeedback uses herbs to reduce inflammation.” c. “Biofeedback requires concentration to control physiological responses.” d. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation.” 137. Client with ALS and has recent weight loss. Which of the following is the priority admission data for the nurse to obtain? a. Changes in appetite b. Swallowing ability c. Prescribed medications d. Daily fluid intake 138. Teaching 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? (OB pg. 60) a. Bleeding gums b. Urinary frequency c. Faintness upon rising d. Swelling of the face 139. Client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care? (medsurg pg. 130) a. Offer the client three large meals each day (increased work of breathing increases caloric demands) b. Limit fluid intake with meals (encourage fluids to promote) c. Administer a bronchodilator after meals d. Ambulate the client before each meal 140. Client experiencing pulmonary embolism. Which of the manifestations should the nurse expect? a. Bradycardia b. Frothy sputum c. HTN d. Dyspnea 141. Client who has permanent drooping on the left side of the face following a CVA. The client refuses to see any family members. Which of the following intervention will best assist the client to adapt to this body image change? a. Establish short-term goals that will enable the client to look in a mirror b. Offer contact information for CVA recovery support groups c. Initiate a family conference to address the issue d. Educate the client about short and long term effects of CVA 142. Caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? a. Discard the open can of formula after 36 hr. b. ADMINISTER FEEDINGS AT A SLOWER RATE (MEDSURG PG. 297: “DIARRHEA – SLOW THE RATE OF FEEDING and notify provider) c. Provide chilled formula d. Flush the tube with 10 mL of water after feedings 143. Providing teaching about exercise to a client who is at 28 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching? a. “I should drink 16-24 oz. of water after I exercise.” b. “I can continue to do exercises that require the supine position.” c. “I SHOULD CHECK MY PULSE RATE ONCE EVERY HOUR WHILE EXERCISING.” d. “I should increase my exercise level to prepare for labor.” 144. Child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? a. Ensure the state health department has been notified b. Administer antitoxin c. Assess for skin necrosis d. Educate the family to avoid sharing personal belongings 145. Teaching about home safety to an older adult client. Which of the following statements by the client indicates that the teaching has been effective? a. “I have grab bars next to my tub.” b. “I have placed throw rugs in the hallways.” c. “I put on socks when getting out of bed at night.” d. “I have marked the steps with black tape.” 146. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? a. The leader lectures about medication adverse effects to the group members b. The leader has group members vote on what they would like to learn about during the session c. The leader allows the group to discuss whatever they would like to regarding their medications d. The leader encourages group members to remain silent until questions are called for 147. A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? a. Establish the responsibilities of the nurse and client b. Determine previous coping skills used by the client c. Facilitate the client’s problem-solving skills d. Assist the client in expressing alternative behaviors 148. A nurse is teaching self-administration of insulin glargine to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. “I will not mix this insulin with other types of insulin.” b. “I will shake the vial to mix the insulin.” c. “I will take this insulin before meals.” d. “I will rotate the injection sites between my arm and my thigh.” 149. Dietary teaching to a client diagnosed with irritable bowel syndrome. Which of the following recommendations should the nurse include? (medsurg pg. 328: “avoid dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspartame”) a. Increase intake of milk products b. Sweeten foods with fructose corn syrup c. Increase intake of foods high in gluten d. Consume food high in bran fiber 150. 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. Place the client in seclusion b. Call the provider for a discharge prescription c. Notify security to monitor the facility’s exits d. Inform the client of the risks involved if she leaves 151. Client having an acute MI. Which of the following findings places the client at risk if he receives alteplase? a. HIP ARTHROPLASTY 1 WEEK AGO b. Family of malignant HTN c. Acute renal failure 6 months ago d. COPD 152. Assessment for a client who is in the manic phase of bipolar disorder. Which of the following behaviors should the nurse expect? a. Performance of ritualistic behaviors b. Distractibility and poor judgment c. Reports of physical discomfort d. Suspiciousness and distrust 153. Toddler who has retinoblastoma. Which of the following findings should the nurse expect? a. White eye reflex nystagmus b. Hyphema c. Opacity of the lens 154. Child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first? a. Refer the family to a chronic pain support group b. Request a change in medication from the provider c. Set up an appointment with the school nurse d. Review the child’s electronic pain diary 155. Client with acute diverticulitis. Which of the following diets should the nurse recommend to the client? a. Lactose-free b. Low-fiber (medsurg pg. 337: “clear liquid diet until manifestations subside; can progress to low-fiber diet as tolerated) c. High residue d. Gluten-free 156. Lab results for a client with heart failure. Serum potassium level of 5.2 mEq/L. Which of the following medications should the nurse withhold? a. Spironolactone b. Metoprolol c. Atorvastatin d. Furosemide 157. Client who is 48 hr. postoperative following a total hip arthroplasty. Which of the following actions should the nurse include in the plan of care? a. Place the client on a full liquid diet b. Administer low-dose heparin c. Maintain the client on bed rest d. Use and incentive spirometer every 3hr 158. A nurse in an acute care facility is caring for a client who is homeless and has a decubitus ulcer. Which of the following actions should the nurse take as a client advocate? a. Gather dressing supplies for the client’s discharge b. Consult with the facility’s quality improvement team c. Contact the facility’s case management department d. Provide client teaching about nutrition 159. A charge nurse observes a coworker who has impaired coordination and is drowsy while performing routine tasks. Which of the following actions should the charge nurse take first? a. Obtain support from another nurse before filing a report b. Document observations about the nurse’s behavior c. Reassign the nurse’s client-care duties to another nurse d. Report the nurse’s behavior to the nurse manager 160. A nurse is caring for a client who has UTI and has been taking cefaclor. Which of the following serum laboratory results indicates the medication is effective? a. Eosinophils 3.9% b. WBC 9,200/mm3 c. Bun 32 mg/dL d. Creatinine 2.3 mg/dL 161. Client who recently attempted suicide states, “I wish I was dead.” Which of the following is an appropriate response by the nurse? a. “Did you take your medications today?” b. “Suicide is not the answer to your problems.” c. “Don’t worry. Everything will be just fine.” d. “You seem like you’re feeling hopeless.” 162. A nurse hears an AP 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. Malpractice b. Battery c. Assault d. Negligence 163. ???? 164. DRUG CALC: 100 mL/hr. 165. ???? 166. Toddler who has cystic fibrosis. Which of the following instructions should the nurse include? a. “Perform chest percussion and postural drainage at least twice daily.” b. “Administer pancreatic enzymes on an empty stomach.” c. “Restrict intake of foods that contain gluten.” d. “Use a nebulizer to administer a bronchodilator following airway clearance therapy.” 167. Which of the following actions should the nurse take to verify NG tube placement prior to each feeding? a. Palpate the abdomen for tube placement b. TEST THE PH OF GASTRIC CONTENTS c. Test the bilirubin level of gastric contents d. Auscultate air insertion into the tube 168. Infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Weak femoral pulses (peds pg. 112) b. Upper extremity hypotension c. Increased ICP d. Frequent nosebleeds 169. Client with 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 (pharm pg. 72: agranulocytosis) 170. Which of the following statements by the newly licensed nurse indicates an understanding of advance directives? a. “I’ll encourage clients to follow their provider’s wishes for end of life care.” b. “I have to document whether or not a client has prepared his advance directives.” c. “I have to witness a client’s signature on his advance directives.” d. “I’ll refer clients who do not have advance directives for legal assistance.” 171. Client who has depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client avoid? a. Smoked salmon b. Cottage cheese c. Spinach d. Grapefruit 172. Client diagnosed of acute MI and is being treated with a thrombolytic, aspirin, and IV heparin. Which of the following findings should indicate the nurse that the client is experiencing a satisfactory response to these interventions? a. Q wave is noted on the cardiac monitor tracing b. S3 heart sounds are present c. The client’s aPTT is two times the control d. The client’s stool is guaiac positive 173. A nurse is assessing the PICC of a client who is receiving an infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse should document the finding as which of the following complications? a. Circulatory overload b. Extravasation c. PHLEBITIS d. Infiltration 174. Which of the following solutions should the nurse use to perform hand hygiene? a. Isopropyl alcohol b. Providone-iodine c. Bleach d. Chlorhexidine 175. Methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Perform exercises prior to bedtime b. Take a 1 hr. nap during the day c. Eat a light snack before bedtime d. Stay in bed at least 1 hr. if unable to fall asleep 176. Which of the following actions by the LPN indicates the need for intervention by the charge nurse? a. Inserts an NG tube for a client using clean technique b. Stabilizes a client’s indwelling urinary catheter with the nondominant prior to inflation of the balloon c. Uses an IV infusion pump to administer TPN nutrition to a client d. Crushes an SL tablet to administer into a client’s feeding tube 177. A 3-day old newborn that has a congenital heart defect. Which of the following interventions should the nurse include to decrease cardiac demands for the newborn? a. Feed the infant when she is awake and crying b. Maintain the infant’s temperature at 37° C (98.6° F) c. Encourage the infant’s parents to limit visitation and physical touch 179. Keep the infant’s bed in a flat position A nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. “The child usually has an aura prior to onset.” b. “This type of seizure can be mistaken for daydreaming.” c. “This type of seizure has a gradual onset.” d. “This type of seizure lasts 30-60 seconds.” 180. A nurse on a medical-surgical unit is delegating tasks to an AP. Which of the following client care tasks is within the scope of practice for the AP? a. Explaining the steps for a 24-hr urine collection b. Assisting with low-carbohydrate diet selections c. Interpreting blood glucose values d. Performing postmortem care [Show More]

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