NURSING Med Surg 2 / SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR / Already Graded A

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1) The nurse would anticipate that the health care provider (HCP) would add which medication to the regimen of the client receiving isoniazid? ✓ Pyridoxine 2) A postpartum nurse is caring for a cl... ient with an epidural catheter in place for opioid analgesic administration following cesarean birth. The client develops respiratory depression and requires naloxone administration. Which finding should the nurse anticipate as a result of the naloxone administration? ✓ Increase in pain level 3) The nurse should monitor the client receiving the first dose of albuterol for which side or adverse effect of this medication? ✓ Tachycardia 4) The client has a prescription to receive pirbuterol 2 puffs and beclomethasone dipropionate 2 puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness? ✓ Administering the pirbuterol before the beclomethasone 5) A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone by inhalation. The client asks why this change is necessary. Which statement by the nurse to the client is accurate? ✓ "Inhaled glucocorticoids are preferred because of decreased adverse effects." 6) A client taking theophylline has a serum theophylline level of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this laboratory value? ✓ In the middle of the therapeutic range 7) A client is taking cetirizine. The nurse should inform the client of which side effect of this medication? ✓ Drowsiness 8) A client is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. Which outcome would the nurse expect as a result of the administration of this medication? ✓ Thinning of respiratory secretions 9) The health care provider prescribes cromolyn for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will produce which effect? ✓ 10) The nurse is teaching a client about the effects of diphenhydramine, an ingredient in the cough suppressant prescribed for the client. The nurse should plan to tell the client to take which measure while taking this medication? ✓ Avoid activities requiring mental alertness. 11) The health care provider (HCP) has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse should teach the client to monitor for which side effect of the medication? ✓ Constipation 12) A client has begun therapy with a xanthine bronchodilator. The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply. ✓ Coffee ✓ Chocolate 13) Which supplies should the nurse obtain for the administration of ribavirin to a hospitalized child with respiratory syncytial virus (RSV)? ✓ A mask and pair of goggles 14) The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first? ✓ Check responsiveness 15) A client is brought into the emergency department in ventricular fibrillation (VF). The nurse prepares to defibrillate by placing defibrillation pads on which part of the chest? ✓ To the right of the sternum and to the left of the precordium 16) An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action ✓ The carotid pulse is palpable with each compression. 17) The nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor. The nurse should immediately take which action? Refer to Figure. View Figure ✓ Initiate cardiopulmonary resuscitation (CPR). 18) To perform defibrillation, the defibrillator pads should be placed in which areas of the client's chest? ✓ To the right of the sternum just below the clavicle and to the left side, just below and to the left of the pectoral muscle 19) The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure. View Figure ✓ Prepare to administer amiodarone. ✓ Prepare to administer epinephrine. ✓ Provide cardiopulmonary resuscitation (CPR). 20) The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? ✓ Apply adhesive patch electrodes to the chest and move away from the client. 21) The nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of laypeople. The nurse observes the group correctly demonstrate 2-rescuer CPR when which ratio of compressions to ventilations is performed on the mannequin? ✓ 30:2 22) The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community members. The nurse tells the group that when chest compressions are performed on infants, the sternum should be depressed how far? ✓ About 1½ inches (4 cm) 23) The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure? ✓ Brachial artery 24) The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? ✓ Maintain manual left uterine displacement during compressions. 25) The nurse is initiating 1-rescuer cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? ✓ On the lower half of the sternum 26) The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? ✓ Use of the head tilt–chin lift 27) The nurse notes that a 14-year-old child is choking but is awake and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. The child becomes unconscious. What procedure should the nurse perform next? ✓ Start chest compressions. 28) The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help? ✓ Perform compressions at 100 to 120 times per minute. 29) The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point? ✓ Brachial 30) External public access defibrillator (PAD) interprets that the rhythm of a pulseless victim is ventricular fibrillation and advises defibrillation. Which action should the rescuer take next? ✓ Order people away from the client, charge the machine, and depress the discharge buttons. 31) Cardiopulmonary resuscitation (CPR) is immediately initiated on a client who is unconscious and has no pulse. A monitor is attached and it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. Which action should the nurse plan to take next? ✓ Perform CPR for 5 cycles, and then defibrillate again if the rhythm is shockable. 32) The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? ✓ Charge the defibrillator. 33) The nurse is teaching chest compressions for cardiopulmonary resuscitation (CPR) to a group of lay clients. Which behavior by one of the participants indicates a need for further teaching? ✓ Letting the right and left fingers rest on the chest 34) In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used. ✓ 1,2,3,4,5 35) One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? ✓ Diphenhydramine 36) The nurse has a prescription to administer whole blood to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size? ✓ 19 gauge 37) A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? ✓ Furosemide 38) The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? ✓ Bottle of albumin with vented tubing 39) The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? ✓ Blood bank 40) The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? ✓ Registered nurse (RN) 41) The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time? ✓ 1330 42) The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? ✓ Circulatory overload 43) The nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1°F (37.8°C). What action should the nurse take first? ✓ Discontinue the infusion and start an infusion of normal saline using new tubing. 44) The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? ✓ Allergic transfusion reaction 45) A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion? ✓ An in-line filter 46) The nurse overhears a health care provider (HCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the HCP will write a prescription for? ✓ Cryoprecipitate 47) The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply. ✓ Chills ✓ Chest pain ✓ Lower back pain ✓ Difficulty breathing 48) A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result? ✓ Blood urea nitrogen level 49) A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when? ✓ The results of spinal radiography are known 50) A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? ✓ Remove the dressing. 51) The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? ✓ Between 18 and 24 hours after the injury 52) The nurse in the recovery room is caring for a client who underwent neurosurgery. Sequential compression devices (SCDs) have been applied to prevent venous stasis. While awaiting client transfer to the intensive care unit, the recovery room nurse should perform which critical assessment? ✓ Monitor vascular status of the lower extremities. 53) A pulmonary artery catheter is inserted into a client during cardiac surgery. The nurse is monitoring the right atrial pressure (RAP). Which finding requires immediate nursing intervention? ✓ 12 mm Hg 54) The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? ✓ "The client should be maintained in a standing position." 55) The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? ✓ Cooling the injury with water 56) The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? ✓ Removing all clothing, including gloves, shoes, and any undergarments 57) A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? ✓ Hypoxia 58) A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? ✓ 100% humidified oxygen by face mask 59) The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn? ✓ Use of accessory muscles for breathing 60) The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? ✓ Assessing peripheral pulses 61) The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? ✓ Elevate the head of the bed. 62) The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? ✓ Monitor mental status every hour. 63) The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? ✓ Monitor the radial pulse every hour. 64) Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route? ✓ By intravenous infusion 65) Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication? ✓ A cardiac monitor 66) The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? ✓ Cut the tube. 67) A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider? ✓ Naloxone 68) The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? ✓ Cardiogenic shock 69) The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? ✓ "Leaking blood vessels have led to decreased protein amounts in the blood." 70) The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment? ✓ Diminished breath sounds 71) The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition? ✓ Level of consciousness 72) The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? ✓ Hematocrit 60% (0.60) 73) The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? ✓ Lung sounds 74) A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart? ✓ Phentolamine 75) Acetylcysteine is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen overdose. The nurse prepares to administer the medication using which procedure? ✓ Diluting the medication in cola and administering it to the client orally 76) A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? ✓ Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. 77) The nurse receives a telephone call from a neighbor, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child's breath smells like the polish, and that spilled polish is present on the front of the child's shirt. What should the nurse tell the mother to do first? ✓ Call the Poison Control Center. 78) The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action? ✓ Position the client in a Fowler's position. 79) The home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by sublingual nitroglycerin tablets given by the nurse. Which action by the nurse would be appropriate at this time? ✓ Call for an ambulance to transport the client to the hospital emergency department. 80) The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? ✓ Urine output of 40 mL/hr 81) A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? ✓ CO 3 L/min, PCWP high 82) A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? ✓ Call the health care provider immediately. 83) The nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest tube accidentally disconnects from the chest drainage system. Which is the initial nursing action? ✓ Place the end of the chest tube in a container of sterile water. 84) The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? ✓ Apply an occlusive dressing. 85) The nurse reviewing the operative record for a client who has just undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. Which intervention is appropriate based on the client's cardiac output reading? ✓ Notify the health care provider (HCP). 86) The nurse has a prescription to administer acetylcysteine to a client admitted to the emergency department with acetaminophen overdose. Before giving this medication, what is the nurse's best action? ✓ Empty the stomach by emesis or lavage. 87) A client with a history of gastric ulcer complains of a sudden, sharp, severe pain in the midepigastric area, which then spreads over the entire abdomen. The client's abdomen is rigid and boardlike on palpation, and the client obtains most comfort from lying in the knee-chest position. The nurse suspects which condition and should perform which action? ✓ Perforation; notify the health care provider. 88) A postoperative client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should assess the client for which change? ✓ Sudden increase in pain 89) A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply. ✓ Administer oxygen. ✓ Obtain an electrocardiogram (ECG). ✓ Contact the health care provider (HCP). ✓ Assess circulation, airway, and breathing. 90) An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply. ✓ Ensure a patent airway. ✓ Obtain a pediatric-size tracheostomy tray. ✓ Prepare the child for a chest radiographic study. ✓ Place the child on an oxygen saturation monitor. 91) A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action? ✓ Contact the health care provider (HCP). 92) The nurse is caring for a client who is receiving feedings by nasogastric tube. The client suddenly begins to vomit, and the nurse quickly repositions the client. The client is coughing and having difficulty breathing. What is the nurse's priority action? ✓ Suction the client. 93) A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? ✓ On the side 94) The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? ✓ Apply firm but gentle pressure with the hands to the flail segment. 95) The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. ✓ Pulsus paradoxus ✓ Distant heart sounds ✓ Falling blood pressure (BP) ✓ Distended jugular veins 96) A client has frequent runs of ventricular tachycardia. The health care provider has prescribed flecainide. What is the best nursing action related to the effects of this medication while the client is hospitalized? ✓ Monitor vital signs and cardiac rhythm frequently. 97) A postpartum client with femoral thrombophlebitis has developed sudden shortness of breath and appears very anxious. What is the nurse's priority action for this client? ✓ Administer oxygen by face mask as per protocol at 8 to 10 L/min. 98) The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs? ✓ The child develops stridor. 99) The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply. ✓ Elevate the extremity above heart level. ✓ Assess the employee for airway or breathing problems. ✓ Examine the amputation site and apply direct pressure to the site using layers of gauze. 100) An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initial treatment? ✓ The administration of an emetic 101) The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Select all that apply. Refer to Figure. View Figure ✓ Oxygen therapy ✓ An echocardiogram ✓ An intravenous dose of metoprolol ✓ A bolus of intravenous heparin followed by a continuous infusion 102) A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? ✓ Call the emergency response team. 103) A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action should the nurse implement? ✓ Maintain a patent airway. 104) The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? ✓ Mix the medication in a flavored ice drink, and allow the client to drink the medication. 105) A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? ✓ `Mediastinal flutter 106) A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first? ✓ Metoprolol 107) A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for? ✓ Pulmonary embolism 108) A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note? ✓ PaO2 49 mm Hg, PaCO2 52 mm Hg 109) The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply. ✓ Notify the health care provider (HCP). ✓ Prepare for endotracheal tube (ET) placement. ✓ Insert an orogastric tube and connect it to low suction. 110) A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider (HCP) suspects appendicitis. Which assessment finding should the nurse immediately report to the HCP? ✓ Sudden relief of abdominal pain 111) The mother of a 3-year-old boy calls the emergency department and states that she found an empty bottle of acetaminophen on the floor. She states that she thinks her child ingested all of the medication. What is the priority question for the nurse to ask the mother? ✓ "Is your child breathing okay?" 112) A 5-year-old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child? ✓ Institute a gastric lavage and administer activated charcoal. 113) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used. ✓ 1,2,3,4,5,6. 114) The nurse is caring for a client who has overdosed on phenobarbital. The nurse anticipates which assessment finding with this client? ✓ Shallow respirations 115) The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client? ✓ Hypertension 116) A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action? ✓ Ensure a patent airway. 117) Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? ✓ Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 118) When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. ✓ Suction the oral cavity whenever needed. ✓ Practice frequent oral hygiene, including teeth brushing. ✓ Wear gloves when suctioning or handling the endotracheal tube. 119) Which step should occur first when using an automated external defibrillator (AED)? ✓ Apply defibrillator pads on the client. 120) Which should the nurse do when setting up an arterial line? ✓ Tighten all tubing connections. 121) Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply. ✓ Monitor vital signs. ✓ Monitor neurological status. ✓ Monitor the dressing for signs of infection. ✓ Monitor for signs of increased intracranial pressure. 122) Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. ✓ Decreased cardiac output ✓ Hyperresonance to percussion ✓ Tracheal deviation to the opposite side 123) A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action? ✓ Notify the health care provider (HCP). 124) A client is admitted to the hospital for an acute episode of angina pectoris. Which parameter is the priority for the nurse to monitor? ✓ Pulse and blood pressure 125) The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? ✓ Epidural hematoma 126) The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? ✓ Autonomic dysreflexia 127) A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. ✓ 1) Raise the head of the bed. ✓ 2) Loosen tight clothing on the client. ✓ 3) Check for bladder distention. ✓ 4) Contact the health care provider (HCP). ✓ 5) Administer an antihypertensive medication. ✓ 6) Document the occurrence, treatment, and response. 128) A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? ✓ Bradycardia 129) The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? ✓ Exert upward pressure against the presenting part. 130) A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply. ✓ Administer oxygen. ✓ Assess the blood pressure. ✓ Start an intravenous (IV) line. ✓ Prepare to administer morphine sulfate. 131) A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication? ✓ Blood pressure 132) A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action? Refer to Figure. View Figure ✓ Contact the health care provider (HCP). 133) The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care? ✓ Administer acetylcysteine. 134) A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign or symptom? ✓ Flushing 135) A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which is the priority nursing action? ✓ Take the client's vital signs. 136) The nurse is admitting a young child who arrived from the emergency department after treatment for acetaminophen overdose. After administering the antidote, the nurse should reassess the child, including which priority laboratory value? ✓ Liver function panel 137) The nurse is monitoring a child who is receiving ethylenediaminetetraacetic acid (EDTA) with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results for the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result? ✓ Blood urea nitrogen (BUN) level 138) The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation? ✓ Level of consciousness 139) A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? ✓ Insertion of a Foley catheter 140) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse should plan for which priority intervention? ✓ Providing assisted ventilation and obtaining the necessary equipment 141) A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse, making rounds at 1545, finds that the client is apprehensive, complaining of a pounding headache, is dyspneic with chills, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? ✓ Shut off the infusion. 142) When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do next? ✓ Apply a sterile dressing soaked with normal saline. 143) The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action should the nurse take? ✓ Obtain a new drainage system. 144) Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)? ✓ A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4°F (38.6°C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg 145) A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? ✓ Assess the client's respiratory status and for the presence of neck injuries. 146) The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? ✓ Rotate the bag gently. 147) The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action? ✓ Remove the IV catheter. 148) The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? ✓ A backflash of blood is noted in the catheter. 149) The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? ✓ Phlebitis of the vein 150) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? ✓ Obtain new IV tubing. 151) A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? a. Sterile 2 × 2 gauze 152) A client complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. ✓ Remove the IV catheter at that site. ✓ Apply warm, moist packs to the site. ✓ Notify the health care provider (HCP). ✓ Document the occurrence, actions taken, and the client's response. 153) A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed? ✓ 5% dextrose in lactated Ringer's 154) The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement? ✓ "I need to restrict my activity while this catheter is in place." 155) A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? ✓ Portable chest x-ray film 156) A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the cardiac step-down unit. The client's blood pressure has been borderline low, and intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular vein for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? ✓ Circulatory overload 157) The nurse in the hospital emergency department is preparing to administer fomepizole to a client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this medication by which route? ✓ Intravenous (IV) route 158) The emergency department nurse is preparing to administer fomepizole to a client suspected of ingesting antifreeze solution during a suicidal attempt. The nurse should prepare to administer this medication by which method? ✓ Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes 159) The emergency department nurse is preparing to administer fomepizole to a client suspected of having ethylene glycol (antifreeze) intoxication. The nurse obtains the vial of medication and notes that the medication has solidified. Which action should the nurse take? ✓ Run the vial under warm water. 160) A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which medication available for local injection if IV infiltration and medication extravasation occur? ✓ Phentolamine 161) A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. A prescription is written to administer sodium nitroprusside by continuous IV infusion. The nurse should plan to do which to administer this medication? ✓ Protect the sodium nitroprusside from light with an opaque material. 162) The nurse has a new prescription to administer verapamil by the intravenous (IV) route. In administering this medication, the most important nursing action should be to use what item to monitor the client's response to the medication? ✓ A cardiac monitor 163) A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? ✓ Discontinuing the infusion after 24 hours 164) A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse should assess for which condition? ✓ Ventricular ectopy 165) The nurse has a prescription to give amiodarone intravenously to a client. What is the priority assessment during administration of this medication? ✓ Cardiac rhythm 166) The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The nurse administers morphine sulfate to the client as prescribed by the health care provider. After administration of the morphine sulfate, what is the priority assessment? ✓ Respirations 167) A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which is the next nursing action for this client? ✓ Administer another nitroglycerin tablet. 168) A client is diagnosed with atrial fibrillation, and the health care provider prescribes medication therapy. Prior to initiating medication therapy, which cardiac rhythm would the nurse expect to note on the cardiac monitor? Click on the image to indicate your answer. ✓ Indication: ✓ 169) A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous (IV) nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, what piece of equipment should the nurse obtain for use at the bedside? ✓ Noninvasive blood pressure monitor 170) A client returning to the nursing unit after a cardiac catheterization procedure has a stat prescription to receive a dose of intravenous procainamide. Which piece of equipment would be most appropriate for the nurse to use in determining the client's response to this medication? ✓ Cardiac monitor 171) A client with heart failure and hypotension has been started on intravenous medication therapy with inamrinone. The nurse determines which finding, if noted in the client, is an adverse effect of the medication? ✓ Decreased blood pressure 172) A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank. ✓ 14,940 mL 173) A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner? ✓ Giving it slowly over 30 to 90 minutes 174) The nurse is administering lidocaine hydrochloride by the intravenous route. Which finding(s) should the nurse report to the health care provider immediately? ✓ Client complaints of blurred vision and nausea 175) The nurse is caring for a client with acute pulmonary edema. The health care provider (HCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the HCP's statement, what medication should the nurse anticipate administering? ✓ Nitroprusside sodium 176) A client is scheduled for placement of a peripherally inserted central catheter (PICC). The nurse has explained the advantages of this catheter to the client. Which statement made by the client indicates a need for further explanation? ✓ "It is specifically designed for short- term use." 177) The nurse in the hospital emergency department is caring for a client with suspected opioid overdose and is preparing to administer the reversal agent via the intravenous route. Which statement is correct about the administration of this medication? ✓ After the initial dose, prepare to administer additional intravenous doses if needed. 178) The nurse is obtaining blood from a client's double- lumen central venous catheter for blood cultures. Which actions are correct for performing this procedure? Select all that apply. ✓ Turn the infusion off for at least 1 minute before obtaining the specimen. ✓ Use the initial specimen of blood obtained from the catheter for the blood cultures. 179) A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse should take? ✓ Stop the infusion. 180) A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred? ✓ Infiltration 181) A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? ✓ On the left side, with the head lower than the feet 182) Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? ✓ Determine whether the client has an allergy to eggs. 183) A client is receiving total parenteral nutrition (TPN). The nurse monitors the client for complications of the therapy and should assess the client for which manifestations of hyperglycemia? ✓ Weakness, thirst, and increased urine output 184) A client has been discharged to home on total parenteral nutrition (TPN). With each visit, the home care nurse should assess which parameters most closely in monitoring this therapy? ✓ Temperature and weight 185) The nurse is performing an assessment on a client who has been receiving total parenteral nutrition (TPN) at 125 mL/hour. On assessment, the nurse notes the presence of bilateral crackles in the lungs and 2+ pedal edema. The nurse also notes that the client has gained 3 pounds (1.5 kg) in 5 days. Which nursing action would be most appropriate for this client? ✓ Notify the health care provider (HCP) of the assessment findings. 186) The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication associated with TPN? ✓ Monitoring the temperatu 187) The nurse is creating a plan of care for a client who is receiving total parenteral nutrition (TPN). Which assessment should be included in the plan of care? ✓ Blood glucose levels every 6 hours 188) Fat emulsion is prescribed for the client receiving total parenteral nutrition. The nurse is preparing to administer the fat emulsion and notes the presence of fat globules in the solution. What should the nurse do? ✓ Return the solution to the pharmacy. 189) A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? ✓ Air embolism 190) A client receiving total parenteral nutrition (TPN) through a single-lumen central intravenous (IV) line is scheduled to receive an antibiotic by the IV route. Which action by the nurse is appropriate before hanging the antibiotic solution? ✓ Ensure a separate IV access for the antibiotic. 191) The nurse notes that a client's total parenteral nutrition (TPN) solution is 4 hours behind. Which action should the nurse take? ✓ Assess the infusion pump to be sure it is functioning properly and is set at the correct rate. 192) A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse? ✓ Place the client on the left side in the Trendelenburg's position. 193) The nurse is preparing to administer lipid emulsion to a client who has just been started on total parenteral nutrition. Before administering the lipid emulsion, the nurse asks the client about allergies. The nurse should withhold the lipid emulsion and contact the health care provider if the client identifies an allergy to which food item? ✓ Soybean oil 194) The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition. What is the nurse's initial action? ✓ Evaluate for signs of septicemia. 195) A client with cancer is placed on permanent total parenteral nutrition (TPN). The nurse considers psychosocial support when planning care for this client when the client makes which correct statement? ✓ "I'll need to adjust to the idea of living without eating by the usual route." 196) The nurse is assigned to a client receiving total parenteral nutrition (TPN) who had a blood glucose measurement done at 06:00. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked next at which time? ✓ 12:00 197) The home care nurse is monitoring a client's response to total parenteral nutrition (TPN). The client's weight 1 week earlier was 114 lbs (52 kg). The nurse determines that the client is gaining weight as expected if which morning weight is noted? ✓ 116 lbs (52.6 kg) 198) What electrolytes and amounts are usually contained in total parenteral nutrition (TPN) for an adult client without renal or hepatic impairment? Select all that apply. ✓ Sodium 1 to 2 mEq/kg ✓ Magnesium 8 to 20 mEq ✓ Potassium 1 to 2 mEq/kg ✓ Phosphate 20 to 40 mmol 199) A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of shakiness and is diaphoretic. Based on these findings, the nurse should perform which assessment next? ✓ Blood glucose level 200) A client with pancreatitis is being weaned from total parenteral nutrition (TPN). The client asks the nurse why the TPN cannot just be stopped. What is the nurse's best response? ✓ Rebound hypoglycemia is a risk. 201) The nurse hears that a client receiving total parenteral nutrition (TPN) at 100 mL/hr has bilateral crackles and 1+ pedal edema during shift report. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lbs (1.8 kg) in 2 days. Which action should the nurse take first? ✓ Compare the intake and output records of the past 2 days. 202) The nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. What assessment should the nurse perform to detect the most common complication of TPN? ✓ Vital signs 203) The community health nurse is providing an educational session to a group of community members regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response should the nurse make? ✓ "A donor must be 18 years of age or older to provide consent." 204) The nurse is caring for a client with terminal cancer who is close to death. On reviewing the plan of care, the nurse determines that which intervention is the priority? ✓ Maintain the client's dignity and self- esteem, and make the client as comfortable as possible. 205) A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider (HCP) that the client had terminal cancer. The HCP examines the client and asks the nurse to contact the medical examiner regarding an autopsy. Family members of the client tell the nurse that they do not want an autopsy performed. Which response to the family is appropriate? ✓ "I will contact the medical examiner regarding your request." 206) The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action? ✓ Ask the client who might be available to serve as a witness. 207) The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death. Which finding indicates to the nurse that the standard for ongoing care has been maintained? ✓ Urine output 100 mL/hr 208) A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? ✓ Administering intravenous (IV) fluids 209) Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply. ✓ Close the client's eyes. ✓ Elevate the head of the bed. ✓ Place wet saline gauze pads and a cool pack on the eyes. 210) The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? ✓ Assess the client's and the spouse's perception of the event. 211) The nurse is caring for a client who is dying. The nurse recognizes that which intervention is likely to facilitate therapeutic communication between the dying client and his or her family? Select all that apply. ✓ The nurse encourages the client and family to identify and discuss feelings openly. ✓ The nurse assists the client and family in carrying out spiritually meaningful practices. ✓ The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. ✓ The nurse is supportive and nonjudgmental of the client's or family's verbalized concerns and feelings. 212) The nurse caring for a terminally ill client has developed a close relationship with the client's family. Which interventions should the nurse include in dealing with the family during this difficult time? Select all that apply. ✓ Encouraging family discussion of feelings ✓ Accepting the family's expressions of anger ✓ Preserving the family's sense of self- direction and control ✓ Maintaining open communication among family members ✓ Facilitating the use of spiritual practices identified by the family 213) The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's sweet-16 birthday party, I'll be ready to die." The nurse notes that the client is experiencing which phase of coping? ✓ Bargaining 214) The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement? ✓ "Palliative care interventions hasten death." 215) The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention? ✓ Encourage the client to maintain maximum self-control. 216) The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply. ✓ Retain ritualism. ✓ Avoid significant changes in lifestyle. ✓ Maintain sensitivity toward the parents. ✓ Encourage the parents to be near the child. ✓ Encourage as normal an environment as possible. 217) The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply. ✓ Loss of consciousness ✓ Loss of bowel control ✓ Loss of bladder control ✓ Decreased blood pressure ✓ Decreased tactile sensation 218) A terminally ill client asks the nurse about hospice care and the nurse educates the client about the hospice program. Which statement by the client indicates that teaching has been effective? ✓ "Clients have a prognosis of 6 months or less to live." 219) The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? ✓ Anxiety 220) The nurse is caring for a dehydrated client who is terminally ill. When caring for this client, the nurse should take which action? ✓ Use moist cloths and swabs for mouth comfort. 221) The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action? ✓ Provide a well-lighted room. 222) The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position? ✓ Lateral 223) The nurse is caring for a terminally ill client who is unresponsive to verbal stimuli. The client's spouse asks if her husband can still hear her. Which is the best response by the nurse? ✓ "Assume that your husband can still hear you." 224) The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which assessment finding should the nurse expect to note? ✓ Periods of apnea followed by deep rapid breathing 225) The nurse is caring for a Hindu client who has just died. The nurse demonstrates cultural awareness when providing postmortem care by taking which action? ✓ Instructing the unlicensed assistive personnel (UAP) to not wash the body 226) The nurse is caring for a dying client who adheres to Judaism. The nurse demonstrates cultural sensitivity when caring for this client by taking which action? ✓ Encouraging a rabbi to sit with the client 227) A client who has been diagnosed with a terminal illness has an advance directive form, needs it to be signed, and asks the nurse to sign it as a witness. What is the nurse's best action? ✓ Ask a nonmedical client, such as a social worker, to witness the form. 228) The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response? ✓ "This must be very hard for you." 229) The nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate? ✓ Elevates the head of the bed 30 degrees as soon as possible after death 230) The hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine? ✓ It helps to reduce anxiety and oxygen consumption. 231) During morning rounds the nurse comes into the room of a client who is unresponsive and near death. Two unlicensed assistive personnel (UAPs) are bathing the client, and their conversation centers on their plans for a weekend party. How should the nurse best intervene? ✓ Remind the UAPs, "Remember that Mr. Smith can hear everything you are saying!" 232) The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do not resuscitate (DNR) prescription. What is the nurse's priority action? ✓ Notify the health care provider (HCP) that the client is rescinding the DNR prescription. 233) The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse should respond by making which statement? ✓ "What do you and your husband believe is the right thing for your children?" 234) The nurse is caring for a terminally ill client. The nurse has developed a close relationship with the family of the client. Which interventions should the nurse employ? Select all that apply. ✓ Encouraging family discussion of feelings ✓ Accepting the family's expressions of anger ✓ Allowing spiritual practices identified by the family ✓ Preserving the family's sense of self- direction and control 235) While the nurse is caring for a client with severe cardiac disease, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which nursing action is appropriate? ✓ Notify the health care provider (HCP) of the client's request. 236) A client brought to the emergency department is dead on arrival (DOA). The health care provider (HCP) examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The spouse of the client tells the nurse that she does not want an autopsy performed. Which response should the nurse make? ✓ "Let me contact your husband's HCP and you can discuss your concerns with him. I will stay with you when you do this." 237) The nurse is instructing a client in breast self- examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? ✓ Left shoulder 238) The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? ✓ At a specific day of the month and on that same day every month thereafter 239) The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? ✓ "This is mostly used in a walk-in clinic or emergency department." 240) The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? ✓ Difficulty walking 241) The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? ✓ "You need to perform BSE on the same day every month." 242) The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? ✓ "It is best to do TSE first thing in the morning before a bath or shower." 243) The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination? ✓ Supine with the head raised slightly and the knees slightly flexed 244) The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? Fill in the blank. ✓ 10 pack-years 245) The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? ✓ Pleural friction rub 246) The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? ✓ Pronator drift 247) The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? ✓ Identify an object placed in the client's hand. 248) The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? ✓ Ask the client to give permission for a family member to stay during the interview. 249) The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. ✓ History of headaches ✓ Previous back injury ✓ History of hypertension ✓ History of diabetes mellitus 250) The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? ✓ Ask the client to follow the flashlight through the 6 cardinal positions of gaze. 251) The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? ✓ Holding the sides of the client's great toe and, while moving it, asking what position it is in 252) A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? ✓ Redness and swelling in the ear canal 253) The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? ✓ Stand 1 to 2 feet (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. 254) The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? ✓ A tuning fork 255) The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? ✓ Stroking the foot from the heel to the toe 256) The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? ✓ Intolerance for sound levels that do not bother other people 257) A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? ✓ Palpating over the breast tissue to assess and compare vibrations from 1 side to the other 258) The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? ✓ Separate the client's jaw by pushing down on the chin. 259) The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over which area? Click on the image to indicate your answer. (Images From Wilson, Giddens [2017].) ✓ The heart is located in the mediastinum. Its apex, or distal end, points to the left and lies at the level of the fifth intercostal space 260) The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status? ✓ The functional status of the vestibular apparatus in the inner ear 261) A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used. ✓ 1) Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client ✓ 2) Asks the client to cover 1 eye ✓ 3) Examiner covers eye opposite to the eye covered by the client ✓ 4) The examiner brings in an object gradually from periphery ✓ 5) Asks the client to report when object is first noted 262) The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? ✓ Focus on a distant object. 263) A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure? ✓ Do the exam on the same day every month. 264) The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. ✓ Tongue ✓ Nail beds ✓ Mucous membranes 265) The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed? ✓ Roll the testicle between the thumb and forefinger. 266) The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? ✓ Snellen chart 267) The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? ✓ Loss of normal red tones in the skin 268) The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? ✓ Oral mucosa 269) The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? ✓ Palpate for increased skin temperature around the wound edges. 270) The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? ✓ "Stand 20 feet (6 meters) from the chart and cover 1 eye." 271) The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? ✓ "The client can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 40 feet (12 meters)." 272) A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? ✓ "I will tell you when the small object is in my visual field." 273) The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? ✓ Mitral area 274) A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? ✓ Just under the left clavicle 275) The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? ✓ Over the fifth intercostal space in the left midclavicular line 276) The nurse is preparing to perform a Weber test on a client who reports a loss of hearing in one ear. To perform the test, the nurse places the tuning fork in which area? Click on the image to indicate your answer. (Image from Jarvis [2015].) ✓ ✓ On the top of the head. 277) The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? ✓ Client reports difficulty sleeping at night. 278) The nurse is documenting the findings of a physical examination in a client's record. Which findings should the nurse determine to be objective data? ✓ The client has a rash on the chest and arms. 279) The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? ✓ A complete health database 280) A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the health care provider's (HCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? ✓ Follow-up database 281) The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? ✓ You can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 30 feet (9 meters)." 282) The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? ✓ A wisp of cotton 283) The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? ✓ The major bronchi 284) The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply. ✓ Muscle strength graded 5/5 ✓ Symmetrical movements bilaterally ✓ Increased muscle size on the dominant arm ✓ A 1-cm hypertrophy of the right upper arm 285) A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment? ✓ Self-care needs such as toileting, feeding, and ambulating 286) The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)? ✓ Pulsation between the umbilicus and the pubis 287) The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? ✓ Number of pack-years 288) A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? ✓ "When was the last time you had your blood pressure checked?" 289) The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply. ✓ Provide sufficient lighting. ✓ Set the room temperature at a comfortable level. ✓ Make sure that the client will be seated comfortably at eye level with the nurse. 290) The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? ✓ Cloves, peppermint, and soap 291) The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test? ✓ The 6 cardinal fields of gaze 292) A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? ✓ The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field. 293) The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination? ✓ Pull the pinna up and back before inserting the speculum. 294) After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? ✓ Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 295) The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment technique should the nurse perform next? ✓ Listen to bowel sounds in all 4 quadrants. 296) The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? ✓ Pain with dorsiflexion of the foot 297) A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? ✓ "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." 298) Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? ✓ Ask the client to shrug the shoulders against the nurse's resistance. 299) When assessing a client's liver during an assessment, the nurse should palpate which abdominal quadrant? ✓ Right upper quadrant 300) A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. The nurse should document this finding as which sound? Play Sound ✓ First heart sound, S1 301) In what area of the chest would the nurse expect to auscultate these breath sounds? Play Sound ✓ Anteriorly and posteriorly over the major bronchi 302) In what area of the chest would the nurse expect to auscultate these breath sounds? Play Sound ✓ Over the peripheral lung fields 303) A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. The nurse should document this finding as which sound? Play Sound ✓ Normal bowel sounds 304) The nurse would perform which action to assess for a pulse deficit? ✓ Auscultate the apical heart beat while palpating the radial artery. 305) The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? ✓ Elevate the shoulders. 306) The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action? ✓ Identify 3 numbers or letters traced in the client's palm. 307) A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. While preparing the nursing care plan for this child, which factor should the nurse take into consideration? ✓ This surgery is taking place at a time when fears of separation are great. 308) The mother of a 16-year-old tells the nurse that she is concerned because her child sleeps about 8 hours every night and until noon every weekend. Which nursing response is most appropriate? ✓ "Adolescents need that amount of sleep every night." 309) The clinic nurse provides information to the mother of a toddler regarding toilet training. Which statement by the mother indicates a need for further information regarding toilet training? ✓ "Bladder control usually is achieved before bowel control." 310) The clinic nurse assesses the communication patterns of a 5-month-old infant. Which assessment finding should lead the nurse to determine that the infant is demonstrating the highest level of developmental achievement expected? ✓ Uses monosyllabic babbling 311. A mother of a 4-year-old expresses concern because her hospitalized child has begun thumb sucking. The mother states that this behavior began 2 days after hospital admission. Which response by the nurse is appropriate? ✓ "It is best to ignore the behavior." 312) The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. Which is the correct interpretation of the behavior? ✓ The child exhibits detachment. 313) The registered nurse (RN) is educating a new RN on the "law and order orientation" found in level 2 of Kohlberg's theory of moral development. Which statement by the new RN indicates that the teaching has been effective? ✓ "An example of this is: If I skip down the hall, will the teacher be mad at me?" 314) A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the health care provider (HCP) has prescribed a full liquid diet. Which nursing action would best promote compliance and provide an adequate nutrient value with the full liquid diet for this teenager? ✓ Ask the teenager for food preferences and liquefy these foods using a blender. 315) The nurse in the pediatric unit is admitting a 2½-year- old child. Which stage in Erikson's psychosocial stages of development should the nurse plan care around? ✓ Autonomy versus Shame and Doubt 316) The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which most appropriate intervention? ✓ Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization 317) The clinic nurse has provided instructions about dental care for toddlers to the mother of a 2-year-old child. Which statement, if made by the mother, indicates a need for further instruction? ✓ "Proper dental care is not necessary for a toddler until the permanent teeth erupt." 318) The nurse is caring for a 14-year-old girl who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs? ✓ Let the child wear her own clothing when friends visit. 319) The nurse at a well-baby clinic is assessing the language and communication developmental milestones of a 4- month-old infant. On the basis of the age of the infant, what should the nurse expect to note as the highest-level developmental milestone? ✓ Babbling sounds 320) The nurse at a well-baby clinic is providing nutrition instructions to the mother of a 1-month-old infant. What instruction should the nurse give to the mother? ✓ Breast milk or formula is the main food. 321) The nurse at a well-baby clinic is assessing the motor development of a 24-month-old child. On the basis of the age of the child, the nurse expects to note what as the highest- level developmental milestone? ✓ The child opens a door by turning the doorknob. 322) The pediatric nurse is caring for a hospitalized toddler. What does the nurse determine is the most appropriate play activity for the toddler? ✓ Playing with a push-pull toy 323) A 2-year-old child has been admitted to the hospital for management of pneumonia. The child is placed in an oxygen tent. Taking into consideration the child's age and developmental level and the treatment being administered, which statement is appropriate for the nurse to make to the parents? ✓ "You can sit next to him and hold his hand through the tent, but he needs to remain inside of it." 324) A mother tells the nurse in a pediatrician's office that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse explores which suggestion with the mother to decrease the children's sense of isolation and fear? ✓ Find community after-school programs or activities. 325) The nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that what should be the highest priority? ✓ Protecting the toddler from injury 326) A 10-year-old child has been diagnosed with type 1 diabetes mellitus, and the nurse prepares to educate the family. The child is very active socially and often is away from the parents. Which is the best focus of the nurse's teaching for this client? ✓ The child is taught how to monitor insulin requirements and how to self-administer the insulin. 327) The nurse in the well-baby clinic has provided instructions regarding dental care to the mother of a 10- month-old child. Which statement by the mother indicates a need for further instruction? ✓ "I can coat a pacifier with honey during the day as long as I do not give my child a bottle at nap or bedtime." 328) A 7-year-old child is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child? ✓ A board game 329) The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff? ✓ Two thirds of the distance between the antecubital fossa and the shoulder 330) The mother of a 5-year-old child tells the nurse that the child scolds the floor or a table if she hurts herself on the object. The nurse educates the mother according to Piaget's theory of cognitive development and its terminology and definitions. Which statement by the mother indicates that the teaching has been effective? ✓ "This is an example of animism." 331) The nurse educator is orienting a new nurse to the pediatric unit and is including tips for medication administration. Which statement by the new nurse indicates that the teaching has been effective? ✓ "You need to stop hitting your sister." 332) The nurse is instructing the caregiver of a child about reprimanding the child. The nurse recognizes that additional teaching is needed if the caregiver makes which statement to the child? ✓ "You need to stop hitting your sister." 333) The nurse is caring for a 4-year-old child. When experiencing pain, the nurse anticipates which about the child? Select all that apply. ✓ Views pain as a punishment ✓ Blames someone else for the pain ✓ Believes pain will disappear magically 334) The nurse is observing a caregiver minimize misbehavior when a child is playing with an excessively noisy toy. The nurse recognizes that further instruction is needed about the appropriate way to do this if the caregiver takes which action? ✓ Instructs the child, "Don't touch that toy." 335) A 6-month-old infant is admitted to the hospital. The nurse weighs the infant and notes that the infant's weight is 14 pounds. Which statement by the mother indicates that further teaching is needed? ✓ "I will have to increase his milk intake because he is not gaining enough weight." 336) An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the mother to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the mother that the child is at which stage of Piaget's cognitive development? ✓ Sensorimotor development 337) Which would be the highest expected growth and development occurrences at 9 months of age for an infant who has had appropriate growth assessed at each well-child visit? Select all that apply. ✓ Should be able to say "mama" and "dada" ✓ Will pull up and stand for several seconds holding on to furniture ✓ Will be able to pick up small pieces of food when placed in a high chair 338) Which would be the highest expected growth and development occurrence at 12 months of age for an infant who has had appropriate growth assessed at each well-child visit? ✓ Walks holding on to someone's hand 339) The nurse is preparing to perform a pediatric physical examination. The child refuses to sit on the examining table, screams when the nurse attempts to perform the assessment, and does not make eye contact. What is the most appropriate initial nursing action? ✓ Talk to the parent while ignoring the child. 340) The mother of a toddler informs the nurse that her child has frequent temper tantrums. The nurse should instruct the mother to implement which measure to deal with the temper tantrums? ✓ Ignore the behavior. 341) The nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. What developmental characteristic of this child should the nurse consider? ✓ Fears of mutilation may be present in the child. 342) The nurse working in the outpatient radiology department is giving discharge instructions to a client who has had a bone scan. Which instruction should the nurse include in the client's teaching plan? ✓ Drink extra water for a day or so after the procedure. 343) A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. Which priority action should the nurse include in the client's plan of care to ensure safety? ✓ Remove all metal-containing objects from the client. 344) A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside? ✓ Chest tube and drainage system 345) The nurse has a prescription to obtain a 24-hour urine collection in a client with a renal disorder. Which actions should the nurse take when collecting this specimen? Select all that apply. ✓ Explain the procedure to the client. ✓ Save all subsequent voidings after the first void during the 24-hour period. ✓ During the collection period, place the main container on ice or in a refrigerator. ✓ Have the client void at the end time, and place this specimen in the main container. 346) How should the nurse position the client for pericardiocentesis to treat cardiac tamponade? ✓ Supine with the head of the bed elevated at a 45- to 60-degree angle 347) A stool smear for culture needs to be obtained from a client. What steps should the nurse plan to implement when obtaining the specimen? Select all that apply. ✓ Wearing sterile gloves ✓ Using a sterile container ✓ Sending the specimen directly to the laboratory 348) The nurse is caring for a client with possible cholelithiasis who is being prepared for intravenous cholangiography and is teaching the client about the procedure. Which statement indicates that the client understands the purpose of this test? ✓ "They are going to look at my gallbladder and ducts." 349) A client is about to undergo a lumbar puncture (LP). The nurse should tell the client that which position will be used during the procedure? ✓ Side-lying with the legs pulled up and the head bent down onto the chest 350) Following myelography, how should the nurse plan to best position the client? ✓ Head slightly elevated 351) The nurse provides discharge instructions to a client following myelography. Which instructions should the nurse provide? Select all that apply. ✓ Avoid bending over. ✓ Avoid strenuous exercise. ✓ Rest with the head elevated. 352) A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse should anticipate that which treatment measure would most likely be prescribed next for the mother? ✓ A 3-hour glucose tolerance test 353) The nurse is caring for a client who is going to have arthrography with a contrast medium. Which assessment by the nurse would be of highest priority? ✓ Allergy to iodine or shellfish 354) A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How should the nurse describe this test to the client? ✓ The dye injected may cause a warm, flushing sensation. 355) The nurse is preparing to care for a client following a gastroscopy procedure. Which priority component should the nurse include in the nursing care plan? ✓ Check the gag reflex by using a tongue depressor to stroke the back of the client's throat. 356) A client is scheduled for an intravenous pyelogram. Before the test, which is the priority nursing action? ✓ Determine a history of iodine allergy. 357) The nurse is caring for a client who has undergone renal angiography using the left femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which finding is observed? ✓ Pallor and coolness of the left leg 358) Cardiac magnetic resonance imaging (MRI) is prescribed for a client. When providing teaching, what does the nurse include as one of the major advantages of this test? ✓ It doesn't require any radiation. 359) The nurse explains to a client why telemonitoring is needed. What response by the client indicates a need for further instruction? ✓ "Telemonitoring ignores artifact." 360) The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen? ✓ Having the client take 3 to 4 deep breaths 361) A female client is scheduled to have a chest radiograph. Which question is most important for the nurse to ask when assessing this client? ✓ "Is there any possibility that you could be pregnant?" 362) A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention should the nurse implement? ✓ Ensuring the return of the gag reflex before offering food or fluids 363) The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse should make which interpretation about this result? ✓ Higher than normal, indicating pheochromocytoma 364) With a finger sensor the nurse is measuring a client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action? ✓ Check the finger sensor's position and repeat the test. 365) The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention should the nurse employ before treatment? ✓ Evaluate the client's visual acuity. 366) A client is scheduled to have a needle liver biopsy. During the procedure, the nurse should instruct the client to take which action? ✓ Lie supine with the right arm over the head. 367) The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results? ✓ Negative 368) A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which is the appropriate nursing intervention? ✓ Withhold oral fluids until the client's gag reflex has returned. 369) The nurse is assisting the health care provider during a colonoscopy procedure. The nurse helps the client to assume which position for the procedure? ✓ Left Sims' 370) A client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse should provide a list of foods from which diet type? ✓ Fat-free 371) The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed? ✓ Ask the client to save a sample voided at the end of the collection time. 372) A client is being scheduled for a positron emission tomography (PET) scan of the brain. The nurse should provide which explanation to the client? ✓ "The test detects abnormal glucose metabolism in the brain." 373) The nurse is explaining to a client what electroencephalography (EEG) involves. What response by the client indicates that further teaching is needed? ✓ "This test is minimally invasive." 374) The nurse explaining the procedure of indium imaging to a client with a bone infection should include which information? ✓ Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone. 375) A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L. How should the nurse interpret this finding? ✓ Suggestive of CF 376) The nurse reviews the health care provider's (HCP's) prescriptions for a child with a streptococcal infection. The HCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis should the nurse suspect in the child? ✓ Rheumatic fever (RF) 377) A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client? ✓ Supine, with the head of the bed elevated about 15 degrees 378) The nurse is assisting the health care provider with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which position? ✓ Right side-lying, with a small pillow or towel under the puncture site 379) The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? ✓ Left side-lying position, with the head of the bed elevated 45 degrees 380) A client is about to undergo a lumbar puncture (LP). Which position should the nurse tell the client will be used during the procedure? ✓ Side-lying position, with legs pulled up and head bent down onto the chest 381) The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result? ✓ Ascorbic acid 382) The nurse is caring for a client with a peptic ulcer who has just had an esophagogastroduodenoscopy (EGD). Which client problem should be the priority? ✓ Risk for choking and aspiration related to a poor gag reflex postprocedure 383) A registered nurse is evaluating the licensed practical nurse's ability to collect a specimen. The nurse would use this specimen collection container to collect which type of specimen? Refer to Figure. (Figure from Perry, Potter, Ostendorf [2014], p. 1074.) View Figure ✓ Respiratory secretions 384) A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? ✓ High-fiber diet 385) The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? Click on the image to indicate your answer. ✓ Correct Answer Indication: ✓ 386) A cold, moist compress is prescribed to be applied to the client's right knee. Which should the nurse plan for? ✓ Ensure that the temperature of the compress is 15°C (59°F). 387) Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position? ✓ It facilitates instillation of the enema solution into the colon. 388) The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position? ✓ Left-sided lateral Sims' position 389) The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next? ✓ Insert the catheter 7 to 9 inches (18 to 23 cm) farther, and then inflate the balloon. 390) The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? ✓ Aspirate the fluid, advance the catheter farther, and reinflate the balloon. 391) The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. ✓ Bounding pulse ✓ Difficulty breathing ✓ Presence of dependent edema ✓ Neck vein distention in the upright position 392) The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? ✓ Changes in mental status 393) The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? ✓ A urine specific gravity of 1.043 394) A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? ✓ Resume full activity level. 395) The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? ✓ Daily weight 396) The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? ✓ Respiratory depression 397) A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do? ✓ Stop administering the enemas until the health care provider (HCP) is notified. 398) The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. ✓ Ensure adequate oxygenation. ✓ Provide assistance to prevent falls. ✓ Monitor medication administration of diuretics. ✓ Prevent complications during potassium administration. 399) A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? ✓ Muscle weakness 400) The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? ✓ Urine specific gravity of 1.032 401) The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? ✓ Heparin 402) The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? ✓ 24-hour fluid intake and output without restricting food or fluid intake 403) A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. ✓ Blood transfusions ✓ Bleeding or hemorrhage ✓ Ingestion of potassium in medications ✓ Failure to restrict dietary potassium 404) The nurse is caring for a client with chronic kidney disease. The nurse knows that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply. ✓ Help regulate blood pressure. ✓ Assist to regulate acid-base balance. ✓ Convert vitamin D to an active form. ✓ Produce erythropoietin for red blood cell synthesis. 405) A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. ✓ Dehydration ✓ Physiological stress ✓ Decreased blood volume 406) The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching? ✓ "This test measures the levels of all of the medications that I take." 407) The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored? ✓ Hyperkalemia 408) The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? ✓ Monitor the client for dysrhythmias. 409) A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? ✓ Asks the athletes to take a salt tablet before football practice 410) The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? ✓ Pour the aspirate into the NG tube through a syringe with the plunger removed. 411) The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank. ✓ 30 mL 412) The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? ✓ Loss of deep tendon reflexes 413) Which clients are most likely to be at risk for the development of third spacing? Select all that apply. ✓ The client with cirrhosis ✓ The client with liver failure ✓ The client with chronic kidney disease 414) The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first? ✓ Contact the health care provider (HCP). 415) A client is brought to the emergency room with a snake bite to the arm. Which treatment interventions should the nurse anticipate? Select all that apply. ✓ Deliver supplemental oxygen. ✓ Maintain the extremity at the level of the heart. ✓ Infuse crystalloid fluids through 2 large- bore intravenous (IV) lines. ✓ Immobilize the affected extremity in a position of function with a splint. 416) The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. ✓ 10% dextrose in water ✓ 5% dextrose in 0.9% saline ✓ 5% dextrose in 0.45% saline ✓ 5% dextrose in lactated Ringer's solution 417) The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? ✓ Sodium chloride 418) The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? ✓ Prolonged bed rest 419) The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level? ✓ Depressed ST segment 420) During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? ✓ Check skin turgor over the client's sternum. 421) During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? ✓ Dehydration 422) The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. ✓ Ensure adequate fluid intake. ✓ Implement safety measures to prevent falls. ✓ Instruct the client about foods that contain potassium. ✓ Encourage the client to obtain assistance to ambulate. 423) A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? Click on the Question Video button to view a video showing preparation procedures. ✓ Pulling up and releasing the skin on the sternal area 424) The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? ✓ Potassium 3.0 mEq/L (3.0 mmol/L) 425) The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? ✓ Hypotension 426) The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply. ✓ Tetany ✓ Hypotension ✓ Prolonged QT interval ✓ Positive Chvostek's sign 427) The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? ✓ Client with an ischemic stroke 428) The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? ✓ Client with diabetes insipidus 429) The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? ✓ A client admitted 6 hours ago with a 40% burn injury 430) The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? ✓ 0.9% sodium chloride 431) The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? ✓ Areflexia 432) The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? ✓ "I drink hot chocolate before bedtime." 433) The nurse is caring for an older client who is complaining of insomnia. What are some of the contributing factors to insomnia in the acute and long-term care setting? Select all that apply. ✓ Pain ✓ Chronic disease ✓ Staff conversations ✓ Environmental noise and lighting 434) A client has a problem with sleeping at night. The nurse encourages the client to do which measure to best enhance nighttime sleep? ✓ Drink a glass of milk. 435) The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client? ✓ The client will function at the highest level of independence possible. 436) Which interventions are appropriate when administering a tepid bath to a child with a fever? Select all that apply. ✓ Use a water toy to distract the child during the bath. ✓ Place lightweight pajamas on the child after the bath. ✓ Squeeze water over the child's body, using the washcloth. 437) A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission? ✓ The disease is transmitted by droplet nuclei. 438) The school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list? ✓ Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits. 439) The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observation made by the instructor indicates the need for further teaching? ✓ The student dons the sterile gloves without washing the hands. 440) Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? ✓ Removing the gown without rolling it from inside out 441) The nurse teaches the mother of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the mother indicates a need for further teaching? ✓ "It is all right to share towels and washcloths as long as they are bleached after use." 442) The nurse is assisting a female client to collect a midstream urine specimen. How should the nurse implement aseptic technique? ✓ Making sure that the fingers avoid touching the inside of the collection container 443) The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items? ✓ Wash hands, leave the client's room, and obtain the needed items. 444) The nurse is caring for a client with newly diagnosed human immunodeficiency virus (HIV). Besides preventing the transmission of the disease, what are the goals of medication therapy? Select all that apply. ✓ Decreasing the viral load ✓ Delaying disease progression ✓ Maintaining or increasing CD4+ T cell counts ✓ Preventing HIV-related symptoms and opportunistic diseases 445) The nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease? ✓ "My wife should get the vaccine." 446) The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved? ✓ Avoids transmitting the virus to others in the group home 447) The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement? ✓ "I should use disposable plates, forks, and knives." 448) A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance? ✓ The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. 449) A client with active tuberculosis demonstrates less- than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? ✓ Directly observed therapy 450) Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? ✓ Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant 451) A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction? ✓ "I should use a hot mist vaporizer to liquefy secretions." 452) A client has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client? ✓ White blood cell (WBC) count of 2000 mm3 (2 × 109/L) 453) An unlicensed assistive personnel (UAP) is caring for a client who has an indwelling urinary catheter. Which action by the UAP would indicate the need for further instruction in the care of the client? ✓ Allowed the drainage tubing to rest under the leg 454) A client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What should the nurse tell the UAP? ✓ Standard precautions are sufficient because the disease is transmitted sexually. 455) The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are some of the initial assessment techniques or interventions the nurse should employ? Select all that apply. ✓ Palpation ✓ Inspection ✓ Percussion ✓ Bladder scanner 456) The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason? ✓ Results in detection of a more accurate number of cases 457) A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath? ✓ A gown and gloves 458) The nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care? ✓ Potential for infection 459) The nurse in the health care clinic is preparing to obtain a throat swab for culture in a client suspected of having a beta-hemolytic streptococcal infection. Which actions are appropriate in collecting this specimen? Select all that apply. ✓ Instruct the client to tilt the head back. ✓ Swab the tonsillar pillars and the posterior pharynx wall. ✓ Tell the client that the test will help to identify microorganisms. ✓ Place a tongue depressor on the client's tongue before swabbing the throat. 460) A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription? ✓ Question the health care provider about whether a portable chest radiograph may be obtained. 461) The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client? ✓ Avoid frequent douching. 462) The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan? ✓ Always apply the condom before inserting the penis into the vagina. 463) The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse should ask whether which signs and symptoms have resolved? ✓ High fever, abdominal pain, vomiting, and diarrhea 464) A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic? ✓ Is painless and indurated 465) The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother? ✓ "One week after the onset of jaundice." 466) A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed? ✓ Supine in semi Fowler's 467) The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poster is planned that will list sexual behaviors in 1 of 2 columns, "safe" and "not safe." Which behavior should the nurse place in the "not safe" column? ✓ Use of natural skin condoms 468) A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be? ✓ "The child should be kept home until the antibiotic eye drops have been administered for 24 hours." 469) The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control? ✓ The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing. 470) The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? ✓ Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. 471) A man is admitted to the hospital with the diagnosis of urethritis secondary to chlamydial infection. What precaution should the nurse implement for this client? ✓ Standard 472) The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation? ✓ Ask the nurse to refrain from eating and drinking in that area. 473) The nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has had blood-tinged sputum with previous suctioning. The nurse plans to use which item as part of standard precautions for this client? ✓ Gloves, gown, mask, and protective eyewear 474) The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness? ✓ Raw oysters 475) The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions? ✓ Droplet precautions 476) The nurse is preparing to insert an intravenous (IV) angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site? ✓ Using a circular motion from the center outward 477) The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply. ✓ A 47-year-old mother of a child with cystic fibrosis ✓ A 54-year-old man scheduled for a routine diabetes check ✓ A 35-year-old registered nurse scheduled for an annual pelvic exam ✓ An 87-year-old woman from a nursing home scheduled for a surgical follow-up 478) The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? ✓ Ceftriaxone 479) An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information? ✓ "My contact lenses can be worn if they are cleaned properly." 480) The nursing instructor determines that the nursing student understands the purposes of standard and transmission-based precautions if which statements are made? Select all that apply. ✓ "They prevent transmission of organisms from client to client." ✓ "They prevent transmission of organisms from health care providers to clients." ✓ "They prevent transmission of organisms from clients to health care providers." ✓ "They prevent transmission of organisms from health care providers and clients to people outside of the hospital." 481) A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs? ✓ Three sputum cultures are negative. 482) The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse should plan to admit the client to a room that has which properties? ✓ Venting to the outside, 6 air exchanges per hour, and ultraviolet light 483) The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement should the nurse make to the client? ✓ Hands should be washed thoroughly before holding the infant. 484) A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching? ✓ "It is a fast-growing infectious disease." 485) The home health nurse visits a client with suspected scabies. Which precaution should the nurse institute during the assessment of the client? ✓ Wear a gown and gloves. 486) The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention? ✓ Private room, gown, gloves, and face shield 487) A man has been admitted to the surgical unit after hernia repair surgery. The medical record reports that the client is human immunodeficiency virus (HIV) positive. The nurse should implement which precautions for this client? ✓ Standard precautions 488) The nurse is providing orientation to a newly graduated nurse. During a discussion of isolation procedures, which statement by the graduate nurse indicates a need for further review of isolation guidelines? ✓ "I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room." 489) The nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What should the nurse do next? ✓ Discard the IV tubing and use a new set for the infusion. 490) A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear? ✓ High-efficiency particulate air (HEPA) filter mask 491) The nurse prepares the client for irrigation of an abdominal wound. After preparation, the nurse would appropriately don which item to perform the procedure? Click on the Question Video button to view a video showing preparation procedures. ✓ Gloves, gown, and goggles 492) The nurse is providing home care instructions to the mother of a child who has bacterial conjunctivitis. The nurse should provide the mother with which information? ✓ The child's towels and washcloths should not be used by other members of the household. 493) The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others? ✓ Blood and body fluid precautions 494) The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which solution to clean the site? ✓ Sterile water 495) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse? ✓ Change the IV tubing. 496) The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which nursing action is most appropriate in preparing the client for the test? ✓ Place a surgical mask on the client for transport. 497) The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results? ✓ Continue monitoring the client. 498) A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. ✓ Lethargy ✓ Headache ✓ Weakness ✓ Confusion 499) The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client? ✓ Respiratory acidosis 500) Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance? ✓ Respiratory alkalosis 501. The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. ✓ Tetany ✓ Tingling ✓ Numbness ✓ Restlessness 502. An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? ✓ Lightheadedness and paresthesias 503. The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention? ✓ Apply a warm compress. 504. A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? ✓ Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. 505. A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care knowing that what reaction is the most powerful regulator of acid- base balance? ✓ Kidney 506. The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply. ✓ Cardiac ✓ Nervous ✓ Neuromuscular 507. The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH? ✓ Fall 508. The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? ✓ Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes 509. A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance? ✓ Metabolic acidosis 510. A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem? ✓ Administer prescribed antibiotics. 511. The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note? ✓ Potassium level of 5.2 mEq/L (5.2 mmol/L) 512. The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? ✓ Metabolic alkalosis 513. The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a Paco2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance? ✓ Respiratory acidosis 514. The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder? ✓ "Do you have a headache or become confused?" 515. The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply. ✓ Stroke ✓ Sleep apnea ✓ Myasthenia gravis ✓ Opioid analgesics, sedatives, anesthetics 516. A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms indicating the acid-base disturbance that could occur in the client? ✓ Headache, nausea, vomiting, and diarrhea 517. The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse should interpret these values as an indication of which condition? ✓ Respiratory alkalosis, uncompensated 518. The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen test on the client. The nurse would perform the steps in which order to conduct an Allen test? Arrange the actions in the order that they should be performed. All options must be used. ✓ 1)Release pressure from the ulnar artery. ✓ 2) Apply pressure over the ulnar and radial arteries. ✓ 3) Ask the client to open and close the hand repeatedly. ✓ 4) Assess the color of the extremity distal to the pressure point. ✓ 5) Explain the procedure to the client. ✓ 6) Document the findings. 519. A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation? ✓ "This test is done to ensure adequate collateral circulation." 520. The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. What is the purpose of this type of respiration? Select all that apply. ✓ Blow off carbon dioxide ✓ Correct metabolic acidosis ✓ Correct an acid-base imbalance ✓ Cause respiratory compensation 521. The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition? ✓ Respiratory acidosis, uncompensated 522. A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder? ✓ Metabolic acidosis 523. The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance? ✓ Respiratory acidosis 524. A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance? ✓ Hypokalemia 525. A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status should avoid which action? ✓ Encouraging the client to breathe slowly and shallowly 526. An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid- base disorder? ✓ Provide emotional support and reassurance. 527. A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? ✓ Potassium 528. The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution? ✓ Seizure precautions 529. The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance? ✓ Drowsiness, headache, and tachypnea 530. A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms? ✓ Decreased respiratory rate and depth 531. The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the health care provider about these levels, the nurse should anticipate receiving from the HCP which prescription for this client? ✓ Discontinue nasogastric suctioning. 532. The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority? ✓ Identify the food preferences and methods of food preparation for each client. 533. The nurse is reviewing the plan of care with an Asian American client. The client frequently nods the head during the review. Based upon this behavior, what should be the nurse's next action? ✓ Contact a qualified medical interpreter. 534. The unlicensed assistive personnel (UAP) is assigned to care for a client who is of Asian heritage. The UAP tells the nurse, "I think that my assignment needs to be changed. Every time I try to talk, the client turns away." Which statement is the most appropriate teaching response from the nurse? ✓ "If the client turns away, continue with the discussion." 535. The nurse is conducting an admission assessment on an African American client scheduled for a hernia repair. Which assessment data are of least importance during the initial assessment? ✓ Psychosocial assessment data 536. The nurse is caring for a newly admitted pregnant Hispanic client who refuses to eat her hot supper. What is the next best action by the nurse? ✓ Replace her supper with cold foods. 537. The nurse at a health care clinic is preparing to examine a Hispanic child who was brought to the clinic by the mother. During assessment of the child, the nurse should avoid which action? ✓ Overly admiring the child 538. The nurse is caring for a slightly intoxicated newly admitted Native American client with gallbladder disease. Based on the client's diagnosis, what dietary issue could be causing this client's problem? ✓ Fried bread and mutton prepared in lard 539. The nurse is caring for an Appalachian client. The nurse makes sure to have frequent contact with the client and to initiate many different conversations. What is the best reason why the nurse uses this approach? ✓ The Appalachian client may prefer personal relationships with health care providers and a desire for frequent communication. 540. The nursing instructor is providing a session on cultural beliefs related to health and illness. At the end of the session, the instructor asks a nursing student to describe the beliefs of some African Americans in regard to illness. Which statement would be the best response by the student? ✓ "Illness is a disharmonious state that may be caused by demons and spirits." 541. The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. When planning care, the nurse recognizes that which principles are consistent with dietary kosher laws? Select all that apply. ✓ Eating fish with scales and fins is allowed. ✓ Unleavened bread is eaten during Passover week. ✓ Meat from animals that are vegetable eaters is allowed. ✓ Meat is allowed if the food animal is ritually slaughtered. 542. The nurse is developing a plan of care for a hospitalized Asian American client. The nurse should include which measures in the client's plan of care? Select all that apply. ✓ Limit eye contact. ✓ Clarify responses to questions. ✓ Maintain physical space with the client. 543. The nurse consults with a nutritionist regarding the dietary preferences of an Asian American client. Which food should be included in the dietary plan? ✓ Rice 544. The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply. ✓ Timing ✓ Volume ✓ Voice tone ✓ Ability to share thoughts and feelings 545. The nurse develops a plan of care for a White American client. The nurse considers the practices and preferences of the culture when planning the care, knowing that which are characteristics associated with this ethnic group? Select all that apply. ✓ Community social organizations are important. ✓ Health often is viewed as an absence of disease or illness. ✓ The client will appear stoic when expressing physical concerns ✓ Members usually rely primarily on the modern Western health care delivery system. 546. The nurse calls the dietary department to obtain a dinner meal for a White American client who was admitted to the hospital at 4:00 p.m. The health care provider prescribed a diet "as tolerated." Considering the practices and preferences of the White American culture, which food should the nurse request for the meal? ✓ Sirloin steak and potatoes 547. The nurse is caring for a Hispanic American client admitted with a diagnosis of diabetic ketoacidosis. Several family members are present. What examples of nonverbal communication would the nurse expect? Select all that apply ✓ Dramatic body language ✓ Smiling and shaking hands ✓ Avoiding any confrontations with staff ✓ Using gestures or facial expressions to express emotion or pain 548. The nurse is caring for a non–English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply. ✓ Increasing client safety ✓ Using spiritual practices ✓ Reducing health disparities ✓ Increasing client satisfaction ✓ Preventing misunderstandings between the nurse and the client 549. A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment? ✓ "Do you have any family problems?" 550. The nurse notes that the client whose religion is Orthodox Judaism has received a cheeseburger with fries and skim milk as a beverage. Considering this finding, what is the best nursing action? ✓ Call the dietary department and ask for a replacement meal tray. 551. The nurse is planning to instruct a Hispanic American client about nutrition and dietary restrictions. What factors should the nurse keep in mind when developing this client's plan of care? Select all that apply. ✓ They view food as a primary form of socialization. ✓ Any occasion is seen as a time to celebrate with food. 552. A community health nurse has volunteered to assist in providing health care instructions to a Native American community group. The nurse plans instructions based on the common practices and rituals of this group, knowing that which are associated characteristics of this ethnic group? Select all that apply. ✓ Alcohol abuse is common. ✓ Vitamin D deficiency is a concern. ✓ Corn is an important component of the diet. ✓ This group is at increased risk for gallbladder disease. 553. A home care nurse is assigned to visit a Hispanic American client to perform an admission assessment. On the initial meeting with the client, the nurse should plan to incorporate which social custom? ✓ Greet the client with a handshake. 554. The nurse is developing a postoperative plan of care for a 40-year-old Filipino man scheduled for an appendectomy. What is the primary nursing action to include in the client's plan of care? ✓ For the first postoperative day, offer pain medication on a regular basis as prescribed. 555. The nurse is planning the menu for an Asian American client in collaboration with the hospital dietitian. The meal plan is designed to incorporate which food as a usual component of an Asian diet? ✓ Vegetables 556. The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client? ✓ The nurse secures the assistance of a professional interpreter to communicate with the client. 557. A Native American man comes to the clinic for a physical examination. When asked about mental status, the client acknowledges having visions of his deceased brother and speaks to him when he needs counsel. Which best describes the nurse's assessment of this client's behavior? ✓ The client is demonstrating behavior that may be regarded as normal within his culture. 558. The home care nurse is assigned to visit a Mexican American client to perform an admission assessment. On initially meeting the client, which actions would be considered culturally appropriate? Select all that apply. ✓ Touch the client. ✓ Greet the client with a handshake. ✓ Smile during the admission assessment. ✓ Use affirmative nods during conversations. 559. When counseling a female Amish client regarding gallbladder disease, what action should the nurse take? ✓ Tell the client that at some point the gallbladder may need to be removed. 560. The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply. ✓ "The population served will determine the culturally sensitive resources to use for teaching." ✓ "Assessment of a client's preferred learning approach is essential to facilitate the learning process." ✓ "It is important to have an accurate translator when the nurse and client do not speak the same language." 561. The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action? ✓ Request permission to move the client to a private room and allow the family members to visit. 562. The nurse in an ambulatory care clinic is performing an admission assessment for an African American client who is scheduled for a cataract removal with intraocular lens implantation. Which question would be appropriate for the nurse to ask the client on an initial assessment? ✓ "Do you have any breathing or heart problems?" 563. The nurse is admitting a client and knows that clients typically share information about herbal supplements or therapies only if they are specifically asked. What are some additional things the nurse needs to do when dealing with this topic with clients? Select all that apply. ✓ Use open-ended questions. ✓ Respond to clients with comments that invite an open-minded discussion. ✓ Document the use of any herbal product(s) or dietary supplements in the client record. ✓ Create an accepting and nonjudgmental attitude when assessing use of or interest in herbal products or dietary supplements. 564. The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called? ✓ Cultural imposition 565. The nurse is caring for a Native American client and notices that the client has been mostly silent. What is the best action for the nurse to take? ✓ Accept it because this behavior is normal and makes the client feel comfortable. 566. The nurse is caring for a Chinese client who is in labor. The client is exhibiting facial grimacing and appears to be in pain. When the nurse offers the client an analgesic, the client refuses. The nurse should take which initial action? ✓ Offer an analgesic again. 567. The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch? ✓ Position hands 2 to 4 inches (5 to 10 cm) from the body. 568. The nurse is caring for an Eastern Orthodox client. During Lent, the nurse should offer the client which dietary choice? ✓ Tossed green salad 569. The nurse is planning care for a hospitalized male client who is an Orthodox Jew. Which action by the nurse is best for this client? ✓ Assign a male unlicensed assistive personnel to help the client with his personal care. 570. An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? ✓ Support the client's decision not to receive a blood transfusion. 571. The nurse is collecting data from an African American client scheduled for surgery. Which questions would be most appropriate for the nurse to ask on initial assessment? Select all that apply. ✓ "Do you ever experience chest pain?" ✓ "Do you have any difficulty breathing?" ✓ "Do you frequently have episodes of headache?" 572. The nurse is providing discharge instructions to an Asian American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which nursing action is most appropriate? ✓ Continue with the instructions, verifying client understanding. 573. The nurse is caring for a postoperative general surgery foreign-speaking client with a history of poor nutrition. What are some reasonable issues that can impact this client? Select all that apply. ✓ Longer hospital stays and increased medical costs ✓ Reduced quality of life and increased mortality rate ✓ Impaired wound healing and increased risk of postoperative infection ✓ Impaired functioning of the gastrointestinal (GI) tract, cardiovascular system, respiratory system, and immune system 574. A kosher meal is delivered to a Jewish American client. Which action by the nurse is most appropriate in assisting the client with the meal? ✓ Ask the client to prepare the meal for eating. 575. The nurse is assigned to care for a Hispanic American client. The nurse should plan to use which communication technique that is appropriate for this culture? ✓ Touch when having a conversation 576. The nurse is creating a postoperative plan of care for a Filipino American client scheduled for surgery. The nurse should consider which factors when addressing pain? Select all that apply. ✓ The client has a high tolerance to pain. ✓ Pain medication needs to be offered on a regular basis as prescribed. 577. The nurse is planning the menu for a Chinese American client. Which foods should the nurse plan to include in the dietary plan? Select all that apply. ✓ Broccoli ✓ Green beans 578. The nurse is examining a Hispanic American child who was brought to the clinic by the mother. Which are appropriate nursing actions? Select all that apply. ✓ Taking the child's vital signs ✓ Asking questions about the child ✓ Obtaining an interpreter if necessary 579. The nurse is providing discharge dietary teaching to a client with a history of irritable bowel syndrome (IBS). What comment made by the client tells the nurse that further instruction is needed? ✓ "I'll eat more beans and peas." 580. The nurse is assessing the cultural beliefs of five clients requiring specimen collection for a diagnostic test. Which cultural assessments are correct? Select all that apply. ✓ Insertion of a throat culture swab into the mouth of a Southeast Asian client may be perceived as threatening. ✓ Hindus collecting a stool specimen for a hemoccult screening test need to use the left hand to place the stool onto the Hemoccult card. ✓ Self-urine collection performed by a right- hand–dominant Muslim client may be collected incorrectly because only a Muslim's left hand can be used for dirty activities. 581. A client is scheduled for a Papanicolaou (Pap) smear at the next scheduled clinic visit. The nurse provides instructions to the client regarding preparation for this test. Which statement should the nurse include in the teaching? ✓ The test is painless. 582. The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium? ✓ Decreased blood pressure 583. The nurse assists a health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position? ✓ A right side-lying position with a small pillow or folded towel under the puncture site 584. A client is scheduled for a fiberoptic gastrointestinal procedure. The nurse instructs the client to remain on clear liquids the day before the test because a clear liquid diet supports which action? ✓ Providing little or no residue 585. The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value measures overall kidney function? ✓ Creatinine clearance levels 586. The nurse instructs a female client to obtain a clean- catch urine specimen for culture and sensitivity testing. Which statement by the client indicates that she understands the procedure for collecting the specimen? ✓ "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container." 587. A client is scheduled for a test to detect kidney tumors or cysts. What test is considered safest for the client? ✓ Ultrasonography 588. The nurse is explaining an upper gastrointestinal series to a client and provides the client with the preprocedure and postprocedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for what time period? ✓ 1 to 2 days 589. The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse should expect to delete which prescription on the client's care plan? ✓ Maintain a clear liquid diet for 72 hours. 590. The nurse is scheduling diagnostic tests for a client. Which of the diagnostic tests prescribed should be performed last? ✓ Barium swallow 591. A client is scheduled for an oral cholecystogram. The nurse should plan to prescribe which type of diet for the evening meal before the test? ✓ Low-fat 592. The nurse is preparing a client who is scheduled to undergo cerebral angiography. The nurse should assess the client for which finding? ✓ Allergy to iodine or shellfish 593. The nurse is providing information to a client scheduled for a lumbar puncture. Which information should the nurse provide to the client? ✓ A signed informed consent form will be required. 594. The nurse is assisting the health care provider in performing a lumbar puncture on a client. The nurse prepares the client for the procedure by placing the client in which position? ✓ Fetal 595. A client requires a myelogram, and the ambulatory care nurse is providing instructions to the client regarding preparation for the procedure. Which statement by the client indicates a need for further instruction? ✓ "I need to be sure to eat a full meal before the procedure." 596. A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective? ✓ "The purpose of the test is to provide information about the blood vessels." 597. The nurse is providing instructions to the client scheduled for magnetic resonance imaging. Which instruction should the nurse provide to the client? ✓ Lying still in a flat position for 45 to 60 minutes may be necessary. 598. The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction? ✓ "All medications need to be withheld on the day of the test." 599. The nurse is providing information to a client who is scheduled for an electromyogram. Which statement by the client indicates the teaching has been effective? ✓ "Needles will be inserted into the skeletal muscles." 600. The ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction? ✓ "I can apply heat to the site if it becomes uncomfortable." 601. The nurse is providing instructions to a client who is scheduled for a gallium scan. Which statement made by the client indicates an understanding of the instructions? ✓ "I need to have an injection 2 to 3 hours before the procedure." 602. A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi's sarcoma. The nurse should prepare the client for which test to confirm the presence of this type of sarcoma? ✓ Punch biopsy of the cutaneous lesions 603. The nurse notes that the health care provider has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse should prepare the client for which diagnostic test to confirm this diagnosis? ✓ Culture of the lesion 604. A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse should tell the client that which will be necessary before the procedure is performed? ✓ A signed informed consent form 605. The nurse is providing instructions to a client who has had a bone scan. The nurse should instruct the client to take which measure? ✓ Increase fluid intake for the next 24 to 48 hours. 606. The nurse is caring for a client who has been diagnosed as having an acute kidney injury. What diagnostic test is most effective in confirming this diagnosis? ✓ Renal biopsy 607. A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's health care provider? ✓ Schilling test 608. A clinic nurse is providing instructions to a female client regarding the procedure for collecting a midstream (clean-catch) urine specimen. What should the nurse instruct the client to do? ✓ Begin the flow of urine and then collect the specimen. 609. A nursing student is assigned to an adult client who is scheduled for bone marrow aspiration. The coassigned nurse asks the nursing student about the possible sites that could be used for obtaining the bone marrow. The student demonstrates understanding of the procedure by identifying what as the correct aspiration site? ✓ Iliac crest 610. The clinic nurse has provided instructions to a client who will be reporting to the laboratory the next morning to have blood drawn for a complete blood cell count. Which statement made by the client indicates an understanding of the preparation for this laboratory test? ✓ "There is no special preparation for this test." 611. The nurse is caring for an 8-month-old infant. A urinalysis has been prescribed, and the nurse plans to collect the specimen. Which method should be used for urine collection in an infant? ✓ Attaching a urine collection device to the infant's perineum 612. The nurse is caring for a client just admitted to the critical care unit with a diagnosis of myocardial infarction (MI). In the early period after an MI, why are nutrition interventions and education so important? Select all that apply. ✓ To reduce angina ✓ To cut down on cardiac workload ✓ To decrease the risk of dysrhythmias 613. The emergency department nurse is caring for a client with a suspected diagnosis of meningitis. The nurse should prepare the client for which test to confirm the diagnosis? ✓ Lumbar puncture 614. The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. The nurse anticipates that which diagnostic test will be prescribed to confirm this diagnosis? ✓ Polymerase chain reaction 615. A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? ✓ Ask the client about allergies and previous reactions. 616. A client asks the nurse to explain what is involved in an intravenous fluorescein angiography study of the eye. The nurse should incorporate which statement in the reply? ✓ "Dilating drops will be instilled before the procedure." 617. The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What should the nurse instruct the client to do in preparation for this procedure? ✓ A low-fiber diet needs to be maintained for 1 to 3 days before the test. 618. A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position should the nurse place the client in for the procedure? ✓ Upright and leaning forward with the arms on an over-the-bed table 619. The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure? ✓ A bowel preparation will be needed in preparation for the procedure. 620. The nurse is providing instructions for a client who will collect a stool specimen for an occult blood test. The nurse instructs the client that it is best to avoid which food for 3 days before collection of the stool specimen? ✓ Turnips 621. A quantitative 72-hour fecal fat collection is prescribed by the health care provider. How should the nurse instruct the client to prepare for the specimen collection? ✓ Consume a high-fat diet for 3 days before the test. 622. The ambulatory care nurse is preparing a client who is scheduled for a liver biopsy. The nurse reviews the client's record and expects to note which laboratory results documented in the client's chart? ✓ Prothrombin time 623. The ambulatory care nurse is preparing to assist the health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed? ✓ Supine with the right hand under the head 624. The nurse is developing a plan of care for a client who is scheduled to return to the nursing unit after a liver biopsy. What is the appropriate position for the client? ✓ On the right side 625. The nurse is providing instructions to a client who is scheduled for a hepatobiliary scintigraphy (HIDA) scan. What should the nurse instruct the client to do? ✓ Avoid oral intake except for water on the day of the procedure. 626. The nurse is developing a plan of care for a client who will be returning to the nursing unit after a percutaneous transhepatic cholangiogram. The nurse should include which intervention in the postprocedure plan of care? ✓ Place a sandbag or other approved device over the insertion site. 627. A clinic nurse is providing instructions to a client who is scheduled for a glucose tolerance test. Which instruction should the nurse provide to the client in preparation for the test? ✓ Avoid alcohol, coffee, and tea for 36 hours before and during the test. 628. The nurse is teaching a client about an upcoming colonoscopy procedure. The nurse would include in the instructions the fact that the client will be placed in which position for the procedure? ✓ Left Sims' 629. An ultrasound examination of the gallbladder is scheduled for a client with a suspected diagnosis of cholecystitis. Correct instructions about the procedure should include which statement made by the nurse? ✓ "This test requires that you lie still for short intervals." 630. The nurse is developing a plan of care for a client who has undergone an esophagogastroduodenoscopy procedure. The nurse should include which intervention in the nursing care plan? ✓ Check the gag reflex by using a tongue depressor to stroke the back of the client's throat. 631. The nurse is teaching a client about what to expect during a gallium scan. The nurse should include which item as part of the instructions? ✓ The procedure takes about 30 to 60 minutes to perform. 632. The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse should make which statement to the client? ✓ "Avoid using underarm deodorant on the day of the test." 633. The nurse is caring for a client who is scheduled to have a lumbar puncture (LP). What are some contraindications for a client to have an LP? Select all that apply. ✓ Clients with infection near the LP site ✓ Clients with increased intracranial pressure ✓ Clients receiving anticoagulation medications ✓ Clients who have severe degenerative vertebral joint disease 634. The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen? ✓ Use a sterile plastic container for obtaining the specimen. 635. The nurse is told to draw an arterial blood gas sample with the client on ambient air. The nurse documents in the record that the client was receiving how much oxygen for this procedure? ✓ 21% 636. A client with diabetes mellitus is scheduled for a fasting blood glucose level determination in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information about fluid and food intake, the nurse clarifies by stating that which would be acceptable to consume before the test? ✓ Water 637. A health care provider is about to perform a paracentesis for a client with abdominal ascites. The nurse assisting with the procedure should help the client into which position? ✓ Upright 638. The nurse is planning care for a client returning to the nursing unit after a bone biopsy. Which nursing action would be contraindicated in the postprocedure care for this client? ✓ Place the limb in a dependent position for 24 hours. 639. The nurse is giving postprocedure instructions to a client returning home after arthroscopy of the shoulder. What is the priority instruction for this client? ✓ "Report any fever or redness and heat at the site to your health care provider." 640. The nurse working in a same-day procedure unit is admitting a client scheduled for an arthrogram using a contrast medium. Which is the priority nursing assessment for this client? ✓ Determine if the client has an allergy to iodine or shellfish. 641. The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement should the nurse include when reviewing preparation for the CT with the client? ✓ "Each set of head scans takes less than 5 minutes to perform." 642. A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply. ✓ Dehydration ✓ Catabolic state ✓ High-protein diet ✓ Obstructive uropathy 643. The nurse is collecting a 24-hour composite urine specimen. Besides electrolytes and glucose, what other components are measured? Select all that apply. ✓ Protein ✓ Minerals ✓ Creatinine ✓ 17-ketosteroids ✓ Catecholamines 644. A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply. ✓ Glycosuria ✓ Albuminuria ✓ Dehydration 645. A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets these results as which condition? ✓ Consistent with glomerulonephritis 646. The clinic nurse has obtained a throat culture specimen from a client in whom a throat infection is suspected. The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short staffed and the laboratory assistant will pick up the specimen in 2 hours. Which is the appropriate nursing action? 647. Refrigerate the specimen. 648. The nurse is caring for a pregnant client who is iron deficient. What groups are vulnerable to this condition? Select all that apply. ✓ Alcoholics ✓ Vegetarians ✓ Women of childbearing years ✓ Older people who consume poor diets 649. To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess? ✓ Hepatitis B surface antigen (HBsAg) 650. Which outcome should the nurse expect to observe in the client who is recovering from viral hepatitis without complications? ✓ Decrease in aspartate aminotransferase (AST) 651. The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse should plan to carefully monitor results of which laboratory test for this client? ✓ Blood glucose level 652. A client with trigeminal neuralgia who is receiving carbamazepine 400 mg orally daily has a white blood cell (WBC) count of 2800 mm3 (28 × 109/L), blood urea nitrogen (BUN) of 17 mg/dL (6.12 mmol/L), sodium of 141 mEq/L (141 mmol/L), and uric acid of 5 mg/dL (0.3 mmol/L). On the basis of these laboratory values, the nurse should make which interpretation? ✓ The WBC count is low, indicating a blood dyscrasia. 653. A client has a prescription to have blood drawn to measure peak and trough vancomycin levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn at which time? ✓ 1.5 hours after completion of the scheduled infusion 654. After completing an assessment and reviewing the laboratory test results of a client admitted to the hospital with acute abdominal pain, the nurse should take action for which noted serum amylase level? ✓ 200 Somogyi units/dL (100 U/L) 655. A client is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion? ✓ Ammonia level of 98 mcg/dL (60 mcmol/L) 656. The client is suspected of having a skeletal muscle disorder. Which isoenzyme value reported with the creatine kinase (CK) level should the nurse assess for elevation? ✓ MM 657. The nurse is reviewing an adult male's serum creatinine level of 4.0 mg/dL (353 mcmol/L). What does this level indicate? ✓ Very high, indicating severe renal failure 658. The nurse is reviewing the laboratory results of a serum medication level assay for a client seen in the health care clinic who has been taking phenytoin for the control of seizures. The nurse determines that a subtherapeutic level of phenytoin is present and that additional medication is required if which level is found? ✓ 3 mcg/mL (12 mcmol/L) 659. The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value? ✓ 18 mcg/mL (100 mcmol/L) 660. The nurse checks the laboratory results of a serum medication level assay for a newly admitted client taking digoxin 0.125 mg orally daily. Which value would indicate a therapeutic level? ✓ 0.6 ng/mL (0.76 nmol/L) 661. The nurse is reviewing the results of the electrolyte panel for a client seen in the clinic. The nurse determines that the client's sodium level is normal if which value is noted? ✓ 142 mEq/L (142 mmol/L) 662. The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted ✓ 4.0 mEq/L (4.0 mmol/L) 663. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted? ✓ 110 mg/dL (6 mmol/L) 664. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's platelet level is normal if which value is noted? ✓ 160,000 mm3 (160 × 109/L) 665. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum protein level is normal if which value is noted on the laboratory report? ✓ 7.0 g/dL (70 g/L) 666. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum lipase level is normal if which value is noted on the laboratory report? ✓ 100 U/L (100 U/L) 667. The nurse just completed an assessment and reviewed the laboratory test results for an adult female client seen in the clinic. The client complains of being tired. The nurse determines that the hemoglobin level is normal if which value is noted on the laboratory report? ✓ 14 g/dL (140 mmol/L) 668. The nurse is reviewing the laboratory test results for an adult male client seen in the health care clinic. The nurse determines that the hematocrit level is normal if which value is noted on the laboratory report? ✓ 50% (0.50) 669. A client with diabetes mellitus reports to the clinic for determination of the glycosylated hemoglobin (HbA1c) level. Which value on this laboratory test indicates client compliance with the prescribed diabetic regimen? ✓ 6% 670. The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results? ✓ 1.019 671. The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the white blood cell (WBC) count is normal if which value is noted on the laboratory report? ✓ 8600 mm3 (8.6 × 109/L) 672. The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse reports to the client that the total cholesterol level is within the recommended guidelines if which value is noted on the laboratory report? ✓ 146 mg/dL (4 mmol/L) 673. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which value is noted on the laboratory report? ✓ 20 mg/dL (7.1 mmol/L) 674. A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal? ✓ 400 mg/dL (4.0 g/L) 675. The nurse is reviewing the laboratory blood test results for a client and notes that the hemoglobin S (Hgb S) value is elevated. The nurse determines that this laboratory finding is associated with which condition? ✓ Sickle cell anemia 676. A client is donating blood for a family member who is having surgery. The nurse tells the client that an indirect Coombs' test will be performed on the blood. The client asks the nurse about the purpose of the test. Which response should the nurse provide to the client? ✓ "The test detects circulating antibodies against red blood cells (RBCs)." 677. A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem? ✓ Iron deficiency 678. The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one? ✓ Pernicious anemia 679. The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition? ✓ Infection 680. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse notes that the red blood cell (RBC) count is increased. The nurse interprets that this finding may be related to which condition or treatment? ✓ Corticosteroid therapy 681. The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse determines that this finding occurs in which condition? ✓ Iron deficiency 682. The nurse preceptor and the orientee note that the reticulocyte count for a client is increased. The preceptor determines that the orientee understands the significance of reticulocytes if the orientee makes which statement with regard to red blood cells (RBCs)? ✓ "A reticulocyte is an immature RBC." 683. The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis? ✓ Pernicious anemia 684. The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the hematocrit value is 30% (0.30). The nurse determines that this hematocrit value is most likely to be associated with which condition? ✓ Iron deficiency anemia 685. The nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse should expect the hematocrit level for this client to be noted at which level? ✓ 60% (0.60) 686. The nurse is caring for a client with a diagnosis of fluid volume overload. The nurse reviews the laboratory test results and would expect to note which finding about the hematocrit level? ✓ Decreased 687. The nurse is reviewing the laboratory results of a client admitted to the hospital with a diagnosis of venous thrombosis. The nurse expects the platelet aggregation to be reported as which level in this client? ✓ Increased 688. The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? ✓ Decreased 689. The nurse is reviewing the electrolyte panel results for an assigned client who is taking a potassium supplement. The nurse should determine that a therapeutic effect is present if which value is noted? ✓ 4.0 mEq/L (4.0 mmol/L) 690. The nurse is reviewing the medication list for a client seen in the health care clinic. The nurse determines that which medications will increase the sodium level? Select all that apply. ✓ Anabolic steroids ✓ Oral contraceptives ✓ Nonsteroidal antiinflammatory drugs 691. The nurse is reviewing the laboratory results of estimated glomerular filtration rate (eGFR). What are some conditions that can cause a decreased eGFR? Select all that apply. ✓ Shock ✓ Dehydration ✓ Heart failure (HF) ✓ Cirrhosis with ascites 692. The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that which level indicates the need for follow-up and immediate notification of the health care provider (HCP)? ✓ Calcium 4.0 mg/dL (1.0 mmol/L) 693. The nurse is reviewing the laboratory results from a lumbar puncture performed in a client with a diagnosis of meningitis. Which laboratory findings are expected to be noted with bacterial meningitis? Select all that apply. ✓ Elevated protein level ✓ Increased white blood cells (WBCs) ✓ Elevated cerebrospinal fluid pressure 694. A child is receiving edetate calcium disodium (calcium ethylenediaminetetraacetic acid [EDTA]) by intravenous (IV) infusion for the treatment of lead poisoning. The health care provider (HCP) prescribes a blood level lead concentration measurement. Which action should the nurse take to obtain the blood specimen? ✓ Stop the IV infusion for 1 hour before obtaining the blood. 695. The nurse is admitting a client who has a cough, dyspnea, and abnormal chest x-ray who is otherwise healthy. The client has an elevated serum angiotensin-converting enzyme (SACE) level. Based on this result, what condition is the client at risk for? ✓ Sarcoidosis 696. The hospital code team is responding to a respiratory emergency of a client admitted during the night with a fractured hip and pelvis after a motor vehicle collision (MVC). The client first became confused and then developed dyspnea, chest pain, and a petechial rash on his neck, upper arms, and chest. What condition is this client at risk for? ✓ Fat embolism syndrome (FES) 697. The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP? ✓ Erythrocyte sedimentation rate (ESR) 698. A client with a diagnosis of question of rheumatoid arthritis (RA) is admitted to the unit. What blood tests would the nurse expect to be prescribed to confirm the diagnosis? Select all that apply. ✓ Rheumatic factor ✓ Antinuclear antibody (ANA) ✓ Erythrocyte sedimentation rate (ESR) ✓ Anticyclic citrullinated peptide antibody (anti-CCP) 699. The evening shift nurse is reviewing the laboratory results of a client's urine culture showing 100,000 bacterial units/mL of urine. What should be the nurse's action? ✓ Page the health care provider (HCP) with the results. 700. The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem? ✓ Infection 701. The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply. ✓ Clotting studies ✓ Glucose fasting ✓ Electrolyte levels ✓ Serum creatinine and blood urea nitrogen (BUN) levels 702. A client with cirrhosis is being treated for hypernatremia. On reviewing the laboratory values for the client, the nurse determines that treatment is effective if which laboratory result is noted? ✓ Serum sodium value of 145 mEq/L (145 mmol/L) 703. A client with a diagnosis of hyperphosphatemia has been treated with dietary management and phosphate binding gels. The client reports to the clinic, and the nurse is reviewing the laboratory results. Which reported serum phosphate level would indicate improvement in the client's condition? ✓ 4.0 mg/dL (1.3 mmol/L) 704. The nurse has been giving a client furosemide intravenously for an exacerbation of heart failure. The nurse monitors what potential abnormal blood levels that frequently occur when this medication is administered? Select all that apply. ✓ Serum sodium ✓ Serum potassium 705. The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which conditions? ✓ Heart failure 706. The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul respirations. The nurse knows that the purpose of this type of breathing is to correct what imbalance? ✓ Metabolic acidosis 707. The nurse is reviewing the laboratory test results for a client and notes that the serum potassium level is 5.5 mEq/L (5.5 mmol/L). The nurse understands that this value would be noted in which condition? ✓ Addison's disease 708. The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review? ✓ Prothrombin time (PT) 709. The nurse is reviewing the laboratory test results and notes that the prothrombin time (PT) is 7.0 seconds. The nurse understands that this PT value would be noted in which condition? ✓ Deep vein thrombosis 710. The nurse is caring for a chemotherapy client with a low platelet aggregation level. Which likely caused this decreased platelet production? ✓ Bone marrow suppression 711. The nurse is admitting a client with suspected ascites. What radiology films would initially be prescribed to diagnose ascites? Select all that apply. ✓ Plain film ✓ Scout film ✓ Flat plate of the abdomen ✓ Kidney ureters bladder (KUB) 712. The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition? ✓ Cirrhosis of the liver 713. A client who has a serum potassium (K+) level of 2.9 mEq/L (2.9 mmol/L) tells the nurse that he does not feel like eating lunch. The nurse checks his serum digoxin level from that morning and notes that it is 1.0 ng/mL (1.2 nmol/L). What should the nurse determine about this digoxin level? ✓ Just above the high end of the therapeutic range 714. The nurse is monitoring for agranulocytosis in a client who is taking clozapine. The nurse should check which serum laboratory result to determine the presence of agranulocytosis? ✓ White blood cell (WBC) count lower than normal 715. A client is undergoing a 2-hour glucose tolerance test. The nurse assesses for which client factors that can interfere with the test period results? Select all that apply. ✓ Experiencing stress ✓ Eating a small snack or candy during the test period ✓ Being unable to eat the entire test meal or vomiting some or all of the meal 716. The nurse is evaluating the laboratory test results for a client with diabetes mellitus seen in the health care clinic. The nurse determines that which glycosylated hemoglobin level value shows poor adherence to therapy? ✓ 10% 717. The nurse notes that a client's lithium level is 3.9 mEq/L (3.9 mmol/L). What is the nurse's priority action in response to this finding? ✓ Instituting seizure precautions 718. The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the results indicate a left shift. What are the possible indications for these laboratory results? Select all that apply. ✓ The total number of WBCs ✓ An increased number of bands ✓ The presence of an acute infectious process ✓ An increased number of immature neutrophils 719. An older client is admitted to the hospital with a diagnosis of malnutrition. Other than cognitive status, what other factors can increase the risk of malnutrition and dehydration? Select all that apply. ✓ Physical fatigue ✓ Limited mobility ✓ Sensory decreases ✓ Inadequate dental care 720. An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range? ✓ 48% (0.48) 721. The nurse instructs a client with diabetes mellitus who takes insulin about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse should inform the client that a blood glucose level of which value indicates hypoglycemia? ✓ 60 mg/dL (3.3 mmol/L) 722. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How should the nurse interpret these results? ✓ Client results are within the therapeutic range. 723. The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply. ✓ Leukopenia ✓ Elevated liver enzymes ✓ Elevated serum bilirubin level ✓ Elevated serum erythrocyte sedimentation rate (ESR) 724. The health care provider (HCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed? ✓ "It is an antibody found on the surface of the red blood cell." 725. The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply. ✓ Hold the finger in a dependent position during the test. ✓ Use gentle pressure to obtain an adequate amount of blood. ✓ Obtain the blood specimen by puncturing the lateral side of the finger. 726. The nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30% (0.30). Which action should the nurse take? ✓ Report the abnormally low level. 727. The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism? ✓ An elevated TSH level 728. The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria rescreening blood test. The nurse determines that the parent understands the need for the test when which statement is made? ✓ "It will allow me to institute measures to prevent complications if the level is elevated." 729. The nurse is reviewing the client's results of preadmission laboratory studies for a complete blood count, electrolytes, coagulation studies, and creatinine before a surgical procedure. Which laboratory result should the nurse report immediately to the surgeon? ✓ Hemoglobin (Hgb) level 8.9 g/dL (89 mmol/L) 730. The nurse is caring for a client with Paget's disease who has a serum calcium level of 12.3 mg/dL (3.1 mmol/L). The nurse should check to see that which medication is available in the stock medication supply for possible use to reverse this elevation? ✓ Calcitonin 731. The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. The nurse determines that which is an abnormal finding? ✓ Protein 100 mg/dL (1 g/L) 732. An adult client with a history of seizure disorder is having a routine serum phenytoin level drawn. Which serum phenytoin result indicates that the client is having a therapeutic effect of the medication? ✓ 16 mcg/mL (63.4 mcmol/L) 733. The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? ✓ "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." 734. The long-term care nurse about to give a daily dose of digoxin is told that a serum digoxin level drawn earlier in the day measured 1.4 ng/mL (1.7 nmol/L). Which action should the nurse take first? ✓ Gather data from the client related to signs of toxicity. 735. A client is receiving oral anticoagulant therapy with warfarin. The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse should anticipate which prescription to be prescribed for this client? ✓ Hold the next dose of warfarin. 736. The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take? ✓ Take no action. 737. A client is scheduled to receive a daily morning dose of furosemide. Which client laboratory result warrants a call to the health care provider (HCP) prior to the medication administration? ✓ Serum potassium of 2.8 mEq/L (2.8 mmol/L) 738. The nurse receives a telephone laboratory report indicating that a diabetic client has a glycosylated hemoglobin (HgbA1c) level of 7.6%. In which priority area should the nurse plan to provide diabetic teaching? ✓ Measures to prevent hyperglycemia 739. The nurse is monitoring the client with a serum calcium level of 6.2 mg/dL (1.55 mmol/L). Which findings should the nurse assess for in the client? Select all that apply. ✓ Irritability ✓ Muscle cramps ✓ Tingling sensations ✓ Hyperactive reflexes ✓ Memory impairment 740. The health care provider's prescription reads levothyroxine, 100 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank. ✓ Correct Answer: 1 tablet(s) 741. The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action should the nurse perform when administering this test to the client? ✓ Make a circular mark around the injection site after administration of the tuberculin test. 742. The nurse is reviewing the medication record and notes that a client is to receive heparin 6000 units subcutaneously. The medication label states heparin 10,000 units/mL. How much heparin will the nurse prepare to administer to the client? Fill in the blank. Record your answer using one decimal place. ✓ Correct Answer: 0.6 mL 743. The health care provider prescribes hydromorphone 1 mg intravenously for a client in pain. The medication label states hydromorphone 2 mg/1 mL. The nurse should administer how many milliliters to the client? Fill in the blank. ✓ Correct Answer: 0.5 mL 744. The health care provider prescribes theophylline 0.2 g orally twice daily. The medication label states 100-mg capsules. The nurse should administer how many capsule(s) to the client at the morning dose? Fill in the blank. ✓ Correct Answer: 2 capsule(s) 745. A health care provider prescribes atenolol 0.025 g orally daily. The label on the medication bottle states atenolol 50-mg tablets. The nurse administers how many tablets to the client? ✓ 0.5 746. The health care provider prescribes digoxin 0.25 mg orally daily for a client with heart failure. The medication label states 0.125 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank. ✓ Correct Answer: 2 tablet(s) 747. The health care provider prescribes levothyroxine 0.15 mg orally daily for a client with hypothyroidism. The medication label states 150 mcg per tablet. The home care nurse should instruct the client to take how many tablet(s)? Fill in the blank. ✓ Correct Answer: 1 tablet(s) 748. The health care provider prescribes regular insulin, 6 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 50 units of regular insulin in 100 mL of normal saline. An infusion pump must be used to administer the medication. The nurse should set the infusion pump at how many milliliters per hour to deliver the correct dose? Fill in the blank. ✓ Correct Answer: 12 mL/hour 749. The health care provider prescribes heparin sodium 800 units per hour, to be given by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled heparin 25,000 units in 500 mL of normal saline. An infusion pump must be used to administer the medication. The nurse should set the infusion pump at how many milliliters per hour to deliver the correct dose? Fill in the blank. ✓ Correct Answer: 16 mL/hour 750. Ampicillin sodium 500 mg in 100 mL of normal saline (NS) is to be administered over a period of 45 minutes. The delivery rate (drop factor) is 10 drops (gtt) per mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 22 gtt/min 751. A client is to receive 1000 mL of 5% dextrose in water (D5W) at 100 mL per hour. The delivery rate (drop factor) is 10 drops (gtt) per mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 752. The health care provider prescribes 1000 mL of normal saline (NS) to be infused over a period of 10 hours. The delivery rate (drop factor) is 15 drops (gtt) per mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. ✓ Correct Answer: 25 gtt/min 753. The health care provider prescribes 1000 mL of 5% dextrose in water containing 1.5 mEq of potassium chloride (KCl) per 100 mL to infuse at a rate of 110 mL/hour. The intravenous starts at 0700. At 1300, how many mEq will be left in the remaining amount of fluid? Fill in the blank. ✓ Correct Answer: 5.1 mEq 754. Normal saline 50 mL is to be given by intravenous (IV) infusion over a 15-minute period. The drop factor for the tubing is 10 gtt/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 33 gtt/min 755. A health care provider (HCP) prescribed digoxin 0.25 mg for a client with atrial fibrillation. The medication is available as 0.125-mg tablets. The nurse calculates that the client will receive 2 tablets of digoxin. When the nurse hands the medication to the client, the client looks at the medication and states, "Every time I get chest pain, I will take 1 of these heart pills." After double-checking the dosage calculation, the nurse should make which decision? ✓ Administer the medication as prescribed and calculated, and proceed with further client teaching. 756. A health care provider (HCP) has prescribed prochlorperazine 4 mg intramuscularly for a client who is vomiting. The nurse reads the label on the medication vial and administers how many milliliters to the client? Refer to Figure. Fill in the blank. (Figure from Kee, Marshall, [2012].) View Figure ✓ Correct Answer: 0.8 mL 757. The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV solution is to infuse at 80 mL/hour. At 1200, how much solution will be left to infuse? Fill in the blank. ✓ Correct Answer: 600 mL 758. A health care provider prescribes 500 mL of half normal saline to infuse over 8 hours. The drop factor is 15 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number ✓ Correct Answer: 16 gtt/min 759. A health care provider prescribes 1000 mL of half normal saline to infuse over 10 hours. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 760. A health care provider prescribes 2000 mL of 5% dextrose and half normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 761. A health care provider prescribes 3000 mL of D5W to infuse over a 24-hour period. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 762. A health care provider prescribes 1000 mL of normal saline to infuse over 12 hours. The drop factor is 10 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 14 gtt/min 763. A health care provider prescribes 1000 mL of normal saline to infuse over 6 hours. The drop factor is 15 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 42 gtt/min 764. A health care provider prescribes 1000 mL of normal saline to infuse over 8 hours. The drop factor is 10 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 765. A health care provider prescribes 100 mL of normal saline to infuse over 1 hour. The drop factor is 15 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. ✓ Correct Answer: 25 gtt/min 766. A health care provider prescribes 100 mL of normal saline to infuse over 30 minutes. The drop factor is 15 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. ✓ Correct Answer: 50 gtt/min 767. A health care provider prescribes 1000 mL of normal saline (NS) to infuse over 24 hours. The drop factor is 60 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 42 gtt/min 768. A health care provider's prescription reads phenytoin 0.3 g orally daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank. ✓ Correct Answer: 3 capsule(s) 769. A health care provider's prescription reads 200 mcg orally daily. The medication label reads 0.1 mg per tablet. The nurse administers how many tablet(s) to the client? Fill in the blank. ✓ Correct Answer: 2 tablet(s 770. A health care provider's prescription reads nitroglycerin grains 1/150 sublingually stat. The label on the bottle reads nitroglycerin 0.4 mg/tablet. The nurse prepares how many tablet(s) to administer the correct dose? Fill in the blank. ✓ Correct Answer: 1 tablet(s) 771. A client is due to receive digoxin 0.125 mg by mouth. The nurse prepares to administer the medication and notes that the label on the bottle of pills states that each tablet contains 0.25 mg. The nurse should take which action? ✓ Administer one half tablet of the medication. 772. A health care provider prescribes ketorolac 15 mg intramuscularly stat for a postoperative client in pain. The medication label states ketorolac 30 mg per mL. How many milliliters should the nurse prepare to administer to the client? Fill in the blank. ✓ Correct Answer: 0.5 mL 773. A health care provider prescribes phenytoin 0.1 g orally 3 times a day. The nurse determines that the prescribed dosage is being administered if the client will be receiving a total of how many milligrams in a 24-hour period? Fill in the blank. ✓ Correct Answer: 300 mg 774. A health care provider prescribes atenolol 0.05 g orally daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank. ✓ Correct Answer: 2 tablet(s) 775. A health care provider prescribes regular insulin 5 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 25 units of regular insulin in 50 mL of normal saline. An infusion pump must be used to administer the medication. How many milliliters per hour are required to deliver the prescribed dose? Fill in the blank. ✓ Correct Answer: 10 mL/hour 776. A health care provider prescribes heparin sodium 900 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin 25,000 units in 500 mL of normal saline. An infusion pump must be used to administer the medication. How many milliliters per hour are required to deliver the prescribed dose? Fill in the blank. ✓ Correct Answer: 18 mL/hour 777. Ampicillin sodium 250 mg in 50 mL of normal saline is to be administered over a period of 30 minutes. The drop factor is 10 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 778. A client is to receive 1000 mL of 5% dextrose in water at a rate of 125 mL/hour. The drop factor is 10 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 779. A health care provider prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. ✓ Correct Answer: 25 gtt/min 780. A health care provider prescribes digoxin 0.125 mg to be administered orally. The label on the medication bottle reads 0.25 mg per tablet. How many tablet(s) should the nurse administer? Fill in the blank. Record your answer using one decimal place. ✓ Correct Answer: 0.5 tablet(s 781. A health care provider prescribes an intravenous dose of 250,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units per mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer using one decimal place. ✓ Correct Answer: 0.8 mL 782. A health care provider prescribes 3000 mL of 5% dextrose in water to run over a 24-hour period. The drop factor is 15 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 31 gtt/min 783. A health care provider's prescription reads hydralazine 5 mg intravenously stat. The medication label reads hydralazine 20 mg/mL. The nurse prepares how many milliliters of the medication to administer the correct dose? Fill in the blank. ✓ Correct Answer: 0.25 mL 784. A health care provider prescribes heparin sodium 900 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag that is labeled heparin sodium 20,000 units per 250 mL of 5% dextrose in water. An infusion pump must be used to administer the medication. How many milliliters per hour are required to deliver the prescribed dose? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 11 mL/hour 785. Gentamycin sulfate 80 mg in 100 mL normal saline is to be administered over 45 minutes. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 33 gtt/min 786. Ceftriaxone 1 g in 100 mL normal saline is to be administered over 60 minutes. The drop factor is 10 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 787. The health care provider prescribes 500 mL of 0.9% normal saline to run over 6 hours. The drop factor is 10 drops (gtt) per 1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 14 gtt/min 788. A health care provider prescribes 1 L of lactated Ringer's solution to run over 10 hours. The tubing drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. ✓ Correct Answer: 25 gtt/min 789. The nurse has a prescription to infuse 1000 mL of 5% dextrose in lactated Ringer's solution at 80 mL per hour. The nurse time-tapes the intravenous (IV) bag with a start time of 0900. After making hourly marks on the time-tape, the nurse should note which completion time for the bag? ✓ 2130 790. The nurse has a prescription to infuse 100 mL of antibiotic solution by the intravenous (IV) route over 1 hour. The tubing administration set has a drop factor of 10 drops (gtt) per mL. The nurse would regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 791. Penicillin V (potassium), 75 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The medication label reads penicillin V, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is safe for the child. The nurse prepares to administer how many milliliters per dose to the child? Fill in the blank. ✓ Correct Answer: 3 mL/dose 792. A health care provider's prescription reads acetaminophen liquid, 450 mg orally every 4 hours PRN (as needed) for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 14 mL 793. The health care provider prescribes meperidine 60 mg and atropine sulfate 0.4 mg intramuscularly. The medications are compatible and will be mixed into one syringe. The label on the prefilled meperidine syringe states 100 mg/mL. The label on the prefilled atropine sulfate syringe states 0.4 mg/mL. How many milliliters of meperidine and how many milliliters of atropine sulfate will be prepared for administration? ✓ Meperidine 0.6 mL, atropine sulfate 1 mL 794. The child who weighs 17 lb is to receive 72 mg/kg/day of a prescribed medication intravenously every 4 hours. How many milligrams should the nurse administer to the child in a single dose? ✓ 92.64 795. The health care provider's prescription for an antibiotic reads "500 mg in 250 mL of 5% dextrose in water and administer over 2 hours." The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 796. A health care provider prescribes 3000 mL of 5% dextrose in water (D5W) to infuse over a 24-hour period. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 797. A health care provider prescribes 2000 mL of 5% dextrose and half normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 798. A health care provider's prescription reads "cyanocobalamin (vitamin B12) 1000 mcg by the intramuscular route." The medication label reads "cyanocobalamin (vitamin B12) 0.5 mg/mL." The nurse prepares the medication and administers how many milliliters to the client? Fill in the blank. ✓ Correct Answer: 2 mL 799. A health care provider prescribes 500 mL of normal saline to infuse over 5 hours. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 799) The health care provider prescribes ketorolac 15 mg intravenous push. The medication vial states "30 mg/mL." How many milliliters will the nurse administer? Fill in the blank. ✓ Correct Answer: 0.5 mL 800) Cloxacillin sodium, 200 mg orally every 8 hours, is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 lb. The safe pediatric dosage is 50 mg/kg/day. Which conclusion should the nurse draw concerning the dose prescribed? ✓ The dose prescribed is too high. 800. Diphenhydramine hydrochloride, 25 mg orally every 6 hours, is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. The nurse should determine which concerning the dose prescribed? ✓ The dose prescribed is safe. 801. Morphine sulfate, 2.5 mg intravenous piggyback, is prescribed for a child with cancer. The safe pediatric dose is 0.05 to 0.1 mg/kg/dose. The child weighs 50 kg. The nurse determines which concerning the dose prescribed? ✓ The dose prescribed is within the safe dosage range. 802. Morphine sulfate, 2.5 mg intravenous piggyback in 10 mL of normal saline, is prescribed. The medication label reads "1/15 gr per mL." The nurse should add how many milliliters of morphine sulfate to the 10 mL of normal saline solution? ✓ 0.6 803. The prescription for an infusion of parenteral nutrition reads: Infuse 1800 mL bag over 24 hours. At what rate will the nurse set the infusion pump? Fill in the blank. ✓ Correct Answer: 75 mL/hour 804. A health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 16 gtt/min 805. The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq of KCl per 15 mL. The nurse should prepare how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 11 mL 806. The nurse is preparing to administer a 50-mcg dose of medication to a client. The medication is available in 100 mcg/5 mL. How many mL should the nurse administer? Fill in the blank. ✓ Correct Answer: 2.5 mL 807. A client is prescribed metoclopramide 5 mg IV. How many milliliters should the nurse administer if the available concentration is 10 mg/2 mL? Fill in the blank. ✓ Correct Answer: 1 mL 808. Amoxicillin/clavulanate potassium 500 mg orally every 6 hours is prescribed for a child with an upper respiratory infection. The medication is supplied as 200 mg/5 mL. How many milliliters will be administered in each dose? Fill in the blank. ✓ Correct Answer: 12.5 mL 809. The health care provider prescribes 1000 mL of 0.9% normal saline to run over 8 hours. The drop factor is 10 drops (gtt)/mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 810. A health care provider prescribes morphine sulfate 4 mg, intravenously (IV) stat, for a postoperative client in pain. The medication label states morphine sulfate 2 mg/mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank. ✓ Correct Answer: 2 mL 811. The health care provider prescribes 0.075 g of a medication orally daily. The label on the medication bottle reads 25-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank. ✓ Correct Answer: 3 tablet(s 812. The health care provider (HCP) prescription reads potassium chloride (KCL) 30 mEq to be added to 1000 mL normal saline and administered over a 10-hour period. The label on the medication bottle reads 4 mEq (KCL)/mL. The nurse prepares how many milliliters of KCL to administer the correct dose of medication? Fill in the blank. ✓ Correct Answer: 7.5 mL 813. Ampicillin sodium, 250 mg in 50 mL of normal saline, is being administered over a period of 30 minutes. The drop factor is 10 gtt/mL. The nurse determines that the infusion is running at the prescribed rate if it is delivering how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 814. The health care provider (HCP) prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 gtt/mL. The nurse adjusts the flow rate at how many drops per minute? Fill in the blank. ✓ Correct Answer: 25 gtt/min 815. The client is to receive 1000 mL of D5W at 100 mL/hour. The drop factor is 10 gtt/mL. The nurse adjusts the flow rate to deliver how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 17 gtt/min 816. The health care provider (HCP) prescribes a dose of 250,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record the answer using one decimal place. ✓ Correct Answer: 0.8 mL 817. The health care provider prescribes 500 mL of 0.9% normal saline to run over 6 hours. The drop factor is 10 gtt/mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 14 gtt/min 818. The health care provider's prescription reads cyanocobalamin (vitamin B12) 150 mcg by the intramuscular route. The medication label reads cyanocobalamin (vitamin B12), 100 mcg/mL. The nurse prepares to administer how many mL to the client? Fill in the blank. ✓ Correct Answer: 1.5 mL 819. The health care provider prescribes a bolus of 500 mL of 0.9% normal saline to run over 4 hours. The drop factor is 10 gtt/mL. The nurse plans to adjust the flow rate to how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 820. A child with leukemia is complaining of nausea. The nurse suspects that the nausea is related to the chemotherapy regimen. The nurse, concerned about the child's nutritional status, should offer which item during this episode of nausea? ✓ Cool, clear liquids 821. The health care provider has prescribed a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the tray to be sure that which has occurred? ✓ All food items are liquid at body temperature. 822. The nurse has instructed a client in the foods that are best to consume on a low-fat diet. The nurse determines that the client understands this diet if the client indicates which food item is lowest in fat? ✓ Dry toast and strawberry jelly 823. A client is being seen in the clinic for symptoms of hyperinsulinism. The nurse provides information to the client regarding dietary measures for the condition. Which diet would be most appropriate to suggest to the client? ✓ Small, frequent meals with protein, fat, and carbohydrates at each meal 824. A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hour. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment? ✓ "Enteral feedings require the normal digestive capabilities of the gastrointestinal tract." 825. The nurse is creating a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse should plan to include which intervention in the plan of care? ✓ Check around the stoma site for skin irritation. 826. A client is diagnosed with a moderate case of acute ulcerative colitis. The nurse doing dietary teaching should give the client examples of foods to eat that represent which therapeutic diet? ✓ Low fiber without milk 827. The nurse has determined that an unconscious client is at risk for nutritional problems. Which outcome indicates to the nurse that the goals have not yet been fully met? ✓ Total protein concentration of 4.5 g/dL (45 g/L) 828. The home care nurse is visiting a male client who is recovering at home after suffering a brain attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself and difficulty with swallowing food and fluids. Which would be the initial nursing action? ✓ Observe the client feeding himself. 829. A client has been on total parenteral nutrition (TPN) for 8 weeks at home. The health care provider prescribes that the TPN be weaned by 50 mL per hour per day until discontinued. The client asks the nurse why the TPN cannot just be stopped. The nurse explains that unless the TPN infusions are tapered gradually, the client is at risk for developing which complication? ✓ Hypoglycemia 830. The nurse is providing dietary instructions to a client with a diagnosis of hyperphosphatemia. The nurse determines that the client understands the instructions if the client states the importance of eliminating which item from the diet? ✓ Fish 831. The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron? ✓ Apricots 832. The nurse is providing dietary instructions to a client regarding a high-protein diet. The nurse should instruct the client to consume which food item that is highest in protein content? ✓ 1 cup of cottage cheese 833. The nurse is providing a dietary session to a group of clients about the vitamin content of various foods. The nurse should tell the clients that which food item is highest in vitamin A? ✓ Green leafy vegetables 834. The school nurse is providing a nutritional counseling session to a group of adolescents. The school nurse should instruct the adolescents that which item is a good source of vitamin C? ✓ Sweet potatoes 835. The nurse has provided dietary instructions to a client regarding food items that are high in vitamin B complex. The client demonstrates understanding of the dietary instructions by stating the importance of including which food item in the diet? ✓ Grains 836. The nurse is providing instructions to a client regarding food items that are high in vitamin D. The client demonstrates understanding of the instructions by stating the need to include which food item in the diet? ✓ Milk 837. The nurse is providing instructions to a client with kidney disease about a low-protein diet. The client demonstrates understanding of the dietary instructions by stating the need to limit which food in the diet? ✓ Chicken 838. The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. ✓ Touch ✓ Eye contact ✓ Personal space ✓ Time orientation 839. The nurse is evaluating a client's ability to select food items for a low-potassium diet. Which food item, if selected by the client, would indicate an understanding of this diet? ✓ Cranberry juice 840. The nurse has given dietary instructions to an older female client to minimize the risk of osteoporosis. The client demonstrates understanding of the dietary teaching by stating that she will increase intake of which food? ✓ Milk 841. The nurse is consulting with a dietitian to plan a menu for a client who is on a regular diet and is a vegan. Which food item would the nurse and the dietitian select for the client's meal? ✓ Stir-fried vegetables 842. The home care nurse is conducting a diet history with an older client who lives alone. The nurse finds that the client's typical 24-hour food intake consists of eggs and sausage for breakfast, a fast-food lunch of hamburger and french fries, takeout fried chicken for dinner, and ice cream in the evening. To decrease the risk of cancer, what statement would the nurse make to the client? ✓ "A high-fat diet increases your risk for colon cancer." 843. The nurse is providing instructions to a client with osteoporosis regarding appropriate food items to include in the diet to increase her intake of calcium. The nurse determines the need for further instruction when the woman tells the nurse that she will be sure to increase her intake of which food that is lowest in calcium? ✓ Pork 844. A client has been given a prescription for gemfibrozil. The nurse should instruct the client to limit which food while taking this medication? ✓ Beef 845. The nurse is providing dietary instructions to a client about food items that are high in niacin. Which food item should the nurse recommend as highest in niacin? ✓ Poultry 846. The nurse is providing dietary instructions to a client about food items that are high in vitamin C. Which food item does the nurse recommend as being highest in vitamin C? ✓ Cabbage 847. The nurse is providing dietary instructions to a client about the food items that are high in vitamin K. Which food item does the nurse recommend as being highest in vitamin K? ✓ Spinach 848. The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply. ✓ Infection ✓ Swelling ✓ Hrombophlebitis ✓ Increased joint pain related to mechanical injury 849. The nurse instructs a client about a low-fat diet. Which menu selection indicates that the client understands the nurse's instructions? ✓ Turkey breast, boiled rice, and fruit 850. In planning a low-sodium diet for a client who has recently been diagnosed with heart failure, the nurse should offer the client which food item? ✓ Chicken breast 851. The breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. The nurse should tell the mother to avoid which food? ✓ Milk 852. The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? ✓ Iron deficiency 853. The nurse is providing instructions to a client with hypophosphatemia. Which food item should the nurse instruct the client to avoid? ✓ Cheese 854. The nurse is giving a presentation on good nutrition to a group of teenage mothers. Which level of prevention is the nurse implementing? ✓ Primary level 855. The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority? ✓ Aspiration 856. The nurse is explaining the process of bariatric surgery to a severely obese client who has attended a medically supervised weight loss program for approximately 6 months. The client is considering this procedure. What are some conditions that may interfere with a client's commitment to lifelong behavioral changes and that may lead to poor surgical outcomes? Select all that apply. ✓ Untreated depression ✓ Binge eating disorders ✓ Drug and alcohol abuse ✓ Inability to comply with nutritional recommendations 857. A postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. Which assessment is most important for the nurse to make before advancing the diet to solids? ✓ Ability to chew 858. A client with heart disease is provided instructions regarding a low-fat diet. The nurse should determine that the client understands the diet if the client states that which food item should be avoided? ✓ Avocados 859. A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse should try to limit which food that is most likely to cause this taste for the client? ✓ Beef 860. A nursing student is caring for a client who has been admitted to the hospital with malnutrition. The nursing instructor determines that the student has made a correct assessment of malnutrition consequences if the student documents which noted findings? Select all that apply. ✓ Cachexic ✓ Lethargic ✓ Dry, flaking skin ✓ Poor wound healing 861. The nurse is teaching a client with tuberculosis about nutrition and foods that should be increased in the diet. The nurse should suggest that the client increase which food items? ✓ Meats and citrus fruits 862. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item(s) are acceptable in the diet? ✓ Baked fish 863. The nurse instructs a client who is at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that which food items are lowest in potassium, providing less than 200 mg per serving? Select all that apply. ✓ Grapes ✓ Asparagus ✓ Applesauce 864. The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium. The nurse should tell the client to consume which foods? Select all that apply. ✓ Peas ✓ Cauliflower ✓ Peanut butter ✓ Canned white tuna 865. The nurse is talking to the mother of a 2-month-old infant who is being seen in the health care provider's office for a well-child visit. Which statement by the mother would indicate that further teaching is needed about nutrition for this infant? ✓ "I started my daughter on cereal a week ago, and she loves the rice cereal." 866. The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention? ✓ Nonstop physical activity and poor nutritional intake 867. The nurse is caring for a client with a diagnosis of celiac disease. The nurse recognizes that client teaching has been effective when the client makes which statement? ✓ "I will eat rice cereal for breakfast." 868. The nurse provides dietary instructions to a client at risk for hypokalemia about which foods are high in potassium and should be included in the daily diet. The nurse should tell the client that which fruit is highest in potassium? ✓ Kiwi 869. The nurse should include which item in a list of the most helpful foods for a vegan client wishing to increase foods high in vitamin A? ✓ Carrots 870. A client with hypertension has been prescribed a low- sodium diet. The nurse teaching this client about foods that are allowed should plan to include which food in a list provided to the client? ✓ Summer squash 871. A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. The client expresses concern about performing this procedure at home. What is the nurse's best response? ✓ "Tell me more about your concerns about going home." 872. Which actions should the nurse include when caring for a client with continuous tube feedings through a nasogastric (NG) tube? Select all that apply. ✓ Check the residual every 4 hours. ✓ Check for placement every 4 hours. ✓ Check skin integrity at the site of NG tube insertion. ✓ Check for placement before administering medications. 873. The nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which intervention should the nurse implement to determine the effectiveness of the tube feedings? ✓ Obtain a daily weight. 874. The nurse is providing dietary teaching to a client who is receiving a potassium-retaining diuretic about foods that are low in potassium. Which foods should the nurse include on a list of foods with low potassium content? ✓ Apple 875. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? ✓ The client's pain rating 876. The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate? ✓ Naloxone 877. The nurse is setting up a transcutaneous electrical nerve stimulation unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse should make which interpretation? ✓ The maximal stimulation has been reached, and it should be decreased slightly. 878. The nurse is assessing the status of pain in an alert elderly client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply. ✓ Pain is something that must be lived with. ✓ Nurses are too busy to listen to reports of pain. ✓ Pain signifies a serious illness or impending death. ✓ Reporting pain will result in being labeled as a "bad" client. 879. The nurse is caring for a client who had a cholecystectomy 1 day ago. The nurse plans pain-management techniques, knowing that the severity of the client's pain can be related to which factor? ✓ Positioning of the client during surgery 880. The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed? ✓ Clients in this age group are less sensitive to pain and have a greater pain tolerance. 881. The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting? Select all that apply. ✓ Intranasal spray ✓ Oral transmucosal lozenge ✓ 72-hour transdermal patch ✓ Effervescent buccal oralets 882. The nurse is discussing pain management with a student who is caring for a 1-day postoperative abdominal surgery client who is a known opioid substance abuser. What comment by the student indicates a need for further education? ✓ Opioid substance abusers are less tolerant to opioids and require decreased doses. 883. The nurse is instructing a client about receiving patient-controlled analgesia to control postoperative pain. What comment by the client indicates that further instruction is needed? ✓ "That's great that overdosing can't happen." 884. The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question? ✓ Meperidine hydrochloride by intramuscular route 885. A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy? ✓ Dislodgment of the epidural catheter because the catheter is not sutured in place 886. The nurse works in a long-term care facility, caring for older clients. The nurse should make which interpretation when an older client complains of pain? ✓ Something is wrong, and an assessment should be made. 887. The health care provider (HCP) writes a prescription for acetylsalicylic acid, or aspirin, for a client who was admitted to the hospital with joint pain from rheumatoid arthritis. The nurse contacts the HCP to verify the prescription if which finding is noted in the assessment data? ✓ Gastric ulceration 888. To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first? ✓ Ensure that the client is experiencing adequate pain control. 889. A client with a fractured femur who has had an open reduction–internal fixation is receiving ketorolac. Which assessment measurement will assist the nurse in determining the effectiveness of this medication? ✓ Pain rating 890. The nurse is caring for a client with a back injury sustained 1 year ago. To obtain the most complete assessment data about the client's chronic pain pattern, what should the nurse ask the client? ✓ "Can you describe your daily activities in relation to your pain?" 891. A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? ✓ Assess the child's physical status. 892. A client is being started on tramadol therapy for pain management after a back injury. When educating this client on tramadol therapy, what is the priority? ✓ The client cannot drink alcohol while taking tramadol. 893. The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? Select all that apply. Click on the Question Video button to view a video showing preparation procedures. ✓ "Where is the pain located?" ✓ "What does the pain feel like?" ✓ "How does the pain affect you?" ✓ "What makes your pain better or worse?" 894. The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first? ✓ Stop the IV infusion. 895. The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often? ✓ Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed 896. A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply. ✓ Check the drain for patency. ✓ Observe for bright red bloody drainage. ✓ Maintain aseptic technique when emptying the drain. 897. The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? ✓ Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. 898. A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider? ✓ An anticoagulant 899. The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin should be discontinued. The nurse should make which statement to the client? ✓ "Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference." 900. The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? ✓ Teaching coughing and deep breathing exercises 901. A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem? ✓ Incorporates nonverbal forms of communication as needed 902. A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication? ✓ Dry oral mucous membranes 903. The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform? ✓ Assessing how often the client swallows 904. A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? Select all that apply. ✓ Dry mouth ✓ Pupillary dilation 905. The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list? ✓ Report any signs of respiratory infection to the health care provider. 906. A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure? ✓ The use of Montgomery straps 907. A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? ✓ Appetite 908. The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability? ✓ "Can you share with me any concerns about how this surgery will affect you in the future?" 909. The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? ✓ Bowel sounds are absent. 910. The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction? ✓ "It is all right to ride in a car as much as I want, as long as I am not driving the car." 911. The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? Refer to Figure. (Figure from Potter P, Perry A, Stockert P, Hall A: Fundamentals of Nursing, ed 8, St. Louis, 2013, Mosby.) View Figure ✓ Apply a sterile nonadherent dressing. 912. A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the health care provider's prescriptions and anticipates that which client position will be prescribed? ✓ Semi Fowler's 913. The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? ✓ Maintains inflation of the alveoli 914. A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client? ✓ Cleansing with warm tap water 915. In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? ✓ Assess the client for signs of dizziness and hypotension. 916. A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action? ✓ Roll the client to one side and check her perineal pad. 917. A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period? ✓ Urinary retention 918. The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site? ✓ Change the diapers as soon as they become damp. 919. The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? ✓ Alcohol abuse 920. An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client? ✓ "It is important for you to get out of bed so that calcium will go back into the bone." 921. The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? ✓ Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. 922. A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action should the nurse include in the client's postoperative plan of care? ✓ Changing dressings frequently around the Penrose drain 923. Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery? ✓ Arm edema on the operative side 924. An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? ✓ Nerve and muscle damage 925. The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? ✓ Ensure that the client has voided. 926. When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound? ✓ Apply a sterile dressing soaked with normal saline. 927. The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions should the nurse include include in the postoperative discharge plan of care? Select all that apply. ✓ Wound care ✓ Follow-up care ✓ Activity restrictions ✓ Dietary instructions 928. A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? ✓ Suction the client through the endotracheal tube. 929. When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? ✓ Obtain the client's vital signs. 930. The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? ✓ After maximal inspiration, hold the breath for 10 seconds and then exhale. 931. A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter? ✓ Ask the client to limit motion in the hand attached to the pulse oximeter. 932. Which statement should the nurse initially make to a client who is anxious about having a magnetic resonance imaging test? ✓ "Can you tell me what you know about this test?" 933. The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply. ✓ Assist the client to void before transfer to the operating room. ✓ Check all surgeon's prescriptions to ensure they have been carried out. ✓ Review the client's record for a history and physical report and laboratory reports. 934. The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? ✓ Recheck the vital signs in 15 minutes. 935. Which finding in a postoperative client would be of concern to the nurse? ✓ Blood pressure of 88/52 mm Hg 936. The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply. ✓ Make sure suction is maintained. ✓ Check that the drains are sutured in place. ✓ Compress the reservoir to restore suction after emptying. ✓ Record the amount and color of drainage according to agency protocol or health care provider's orders. 937. The nurse is reviewing the health care provider's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? ✓ Atenolol 938. The nurse is caring for an 18-month-old child who has been vomiting. Which is the most appropriate position for this child while sleeping? ✓ Side-lying position 939. The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? ✓ Unsecured scatter rugs 940. The nurse provides instructions to the parents of an infant regarding car travel and safety seats. Which is the appropriate information related to the safety of the infant? ✓ Restrain in a car seat in the back seat in a semireclined rear-facing position. 941. The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action? ✓ Aspirate the fluid, advance the catheter farther, and reinflate the balloon. 942. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What action should the nurse take next? ✓ Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 943. The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times? ✓ A pair of scissors 944. The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider? ✓ Aspiration is a concern with an NG tube feeding. 945. The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right- sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating? ✓ Quad cane 946. The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client? ✓ Hold the cane on the unaffected (strong) side. 947. The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made? ✓ The client's elbow is flexed at a 15- to 30- degree angle when ambulating with the cane. 948. The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action? ✓ Using a gloved finger to open the client's mouth 949. The mother of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition? ✓ "Do you live in a house that is more than 25 years old?" 950. The community health nurse is performing a safety assessment in the home of a mother with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children? ✓ Toys with small loose parts in the playroom 951. The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction? ✓ "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time." 952. The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client? ✓ Prepare a private room at the end of the hallway. 953. The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? ✓ Apply prolonged pressure to the IM site after the injection. 954. The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? ✓ Review hand washing techniques and pericare procedures with the client. 955. An unconscious client has an impaired corneal reflex on one side. The nurse should demonstrate the best understanding of how to protect the client's eye by performing which action? ✓ Using sterile saline drops every few hours to keep the eye moist 956. A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family? ✓ Encouraging the client to stand unassisted on the leg 957. The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture? ✓ The IV solution for particles or contamination 958. The health care provider (HCP) prescribes fat emulsion, given intravenously, for a client. The nurse should consult with the HCP before administering the fat emulsion solution if which is noted in the client's record? ✓ The client has an allergy to egg yolks. 959. The nurse is providing instructions to an unlicensed assistive personnel (UAP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the UAP to place personal articles for morning care? ✓ Within the client's reach on the left side 960. A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priority action in the care of this client? ✓ Assign the client to a private room. 961. A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard? ✓ Disinfect the toilet with bleach after voiding for 6 hours after a treatment. 962. What action should the nurse take as a priority after administering an opioid analgesic to a client experiencing pain? ✓ Provide safety measures per agency protocol. 963. A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method? ✓ Ventrogluteal muscle using Z-track technique 964. The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What should the nurse's first action be? ✓ Activate the fire alarm. 965. The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicates an understanding of the care for this client? ✓ "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises." 966. The nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care should include nursing interventions that address which early characteristic of Alzheimer's disease? ✓ Forgetfulness interferes with the daily routine. 967. A client has a prescription for an injection to be administered by the intradermal route. The nurse should avoid which action when administering this medication? ✓ Massaging the area after removing the needle 968. The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure? ✓ Rinsing with a large volume of fluid 969. The nurse has instructed a client with a continuous passive motion device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question? ✓ How to reset the degrees of flexion or extension according to comfort 970. The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education? ✓ Properly glazed pottery 971. The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by one of the parents should the nurse identify as something that requires the need for reinforcement of the instructions? ✓ Refers to medication as "candy for when you are sick" 972. The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction? ✓ "When I'm feeling better, I'm returning to the soccer team." 973. The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the coassigned licensed nurse identifies which action as an incorrect intervention? ✓ Using padded restraints to immobilize the limb 974. The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration? ✓ Upright in a chair 975. The nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need? ✓ Assist the client onto a bedpan. 976. The nurse is assessing an older adult who was just admitted to the emergency department with a possible hip fracture. What typical complaints of types and/or locations of pain might the nurse expect? Select all that apply. ✓ No pain ✓ Groin pain ✓ Pain referred to the lower back ✓ Pain referred to the back of the knee 977. The nurse is caring for an older client who had a hip pinned after being fractured. Which should the nurse do to prevent further injury? ✓ Use a night light in the hospital room and the bathroom. 978. A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that further teaching is required if the client performs which action? ✓ Advances the walker with reciprocal motion 979. The nurse has administered diazepam 5 mg by the intravenous route to a client. The nurse should plan to maintain the client on bed rest for at least how long? ✓ 3 hours 980. The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction? ✓ "The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe." 981. The nurse is preparing to administer an intramuscular injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected? ✓ 1.5 mL 982. The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters? ✓ 2 983. The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse should perform which action? ✓ Pulls the pinna of the ear back and down. 984. The home health nurse performs an assessment on a client who had cardiac surgery 10 days ago. The client states, "I get dizzy in the shower." On the basis of the client's statement, which should the nurse assess first? ✓ The temperature of the water of the client's shower 985. The nurse creates a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan? ✓ Place a lead shield at the bedside. 986. The nurse is instructing a client to perform a two- point gait for crutch walking. The nurse should tell the client to perform which action? ✓ Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward. 987. The community health nurse is conducting an education session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time? ✓ One hour before exposure to the sun 988. A community health nurse is preparing to administer a tuberculin skin test. The nurse should select which syringe to administer the medication? Click on the image to indicate your answer. ✓ Correct Answer Indication: ✓ 989. The nurse is transcribing a health care provider's prescription and notes that the client is to receive a medication at 1:00 p.m. Using the military time clock, the nurse documents which military time in the medication record for administration of the medication? Click on the image to indicate your answer. (Figure from Elkin, Perry, Potter: Clinical nursing skills, ed 7, St. Louis, 2012, Mosby.) ✓ ✓1300-1 990. An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury? ✓ Explore the client's knowledge of gun safety. 991. A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure? ✓ Keep traveled paths in the home free of clutter. 992. A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client? ✓ Walker 993. The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority? ✓ Risk for injury 994. The nurse is preparing to infuse (piggyback) a 50-mL dose of a compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag? ✓ Hanging the medication bag higher than the primary IV bag 995. The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients? ✓ Every 1 hour 996. The nurse has a prescription to administer phenytoin by intravenous (IV) push through an IV line infusing 1000 mL of 0.9% sodium chloride. Arrange the actions in the order that they should be performed. All options must be used. ✓ 1) Check the compatibility of phenytoin with the IV solution. ✓ 2) Draw up the medication in a 3-mL syringe. ✓ 3) Check the client's identification (ID) bracelet. ✓ 4)Pinch off the IV tubing above the injection port. ✓ 5) Inject the medication. ✓ 6) Document that the medication was administered. 997. The nurse is making a note in the care plan for a client who has a multilumen central venous catheter. The nurse should write to change the injection caps on the lumens at which times? ✓ Whenever blood is drawn from the lumen 998. A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home? ✓ Have the client verbalize and demonstrate the correct administration procedures. 999. The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation? ✓ Carefully pick up the syringe from the floor and dispose of it in a sharps container. 1000. A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse providing care for the client administers an opioid analgesic to relieve the pain, as prescribed. What is the next nursing action for this client? ✓ Ensure the call bell is within the client's reach. 1001. The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan? ✓ Remove throw rugs and clutter in the home. 1002. A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? ✓ "I will avoid getting the cast wet." 1003. A health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 p.m. to 7:00 a.m. because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 p.m., the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action? ✓ The restraints were applied tightly. 1004. When administering an intramuscular injection in the ventrogluteal muscle, how should the nurse position the client to best relax the muscle? ✓ On the side with the hip and knee of the uppermost leg flexed 1005. The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? ✓ Flush the tubing before and after the medication with normal saline. 1006. The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? ✓ Speak and move slowly toward the client while assessing the client's needs. 1007. The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure ✓ Oil-soluble lubricant 1008. A home care nurse performs a home safety assessment and discovers that a client is using a space heater in the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater? ✓ The space heater needs to be placed at least 3 feet from anything that can burn. 1009. The nurse is preparing to administer an oral medication to an infant. In which position should the nurse place the infant? ✓ Semi Fowler's 1010. The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention? ✓ Place a mattress sensor pad on the bed. 1011. The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Which medication prescription should the nurse question? ✓ Isosorbide mononitrate 30 mg via PEG tube daily 1012. The health care provider (HCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the HCP's prescription and address the needs of the client? ✓ Progressively ambulate the client in the hall three times daily. 1013. The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Which statement should the nurse make to the client before removing the tube? ✓ "Take a deep breath when I tell you, and hold it while I remove the tube." 1014. The nurse is caring for a client with a nasogastric tube connected to continuous suction. During assessment the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which intervention would be most appropriate to maintain the integrity of this client's oral mucosa? ✓ Brush the teeth frequently; use mouthwash and water. 1015. The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube? ✓ Asking the client to swallow as the tube is being advanced 1016. The health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. ✓ Correct Answer: 21 gtt/min 1017. The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply. ✓ The right dose ✓ The right route ✓ The right time ✓ The right client ✓ The right documentation 1018. A client is in the bathroom when the nurse arrives at his room with his scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? ✓ Tell the client you will be back when he is finished. 1019. The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing? ✓ Tertiary level 1020. The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why he is receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication? ✓ "Medications given this way are absorbed more quickly than by other routes." 1021. The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action should the nurse take? ✓ Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. 1022. The nurse is preparing to administer an intradermal medication. Which action should the nurse take before administering the medication? ✓ Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry. 1023. A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period? ✓ Within 20 to 30 minutes of application 1024. The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statemen ✓ "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." 1025. The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is appropriate to prevent these disorders from developing? ✓ Encouraging active range-of-motion exercises 1026. A client has a prescription to receive purified protein derivative, 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines? ✓ 26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up 1027. The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? ✓ Leaves the ulcer open to the air after the enzymatic agent is applied 1028. The nurse prepares to perform nail and foot care on a client. Which interventions should the nurse include in the procedure? Select all that apply. ✓ Use a soft nail brush around the cuticles. ✓ Inspect the nails and feet before and after soaking and cleaning. ✓ Clean under the nails with a plastic stick while the fingers are immersed in water. 1029. The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question? ✓ Hydrochlorothiazide orally twice daily 1030. The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. ✓ Risk for unsafe conditions because of homelessness ✓ Anxiety when consciousness is regained because of the unfamiliar surroundings ✓ Risk for infection because of his unkempt condition, various scratches, and homelessness 1031. The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. ✓ Keep pets and children away from the monitor. ✓ Keep emergency rescue numbers near the telephone. 1032. The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions should the nurse take? Arrange the actions in the order that they should be performed. All options must be used. ✓ 1) Protect the client from injury. ✓ 2)Activate the fire alarm. ✓ 3) Close the doors to the other clients' rooms. ✓ 4) Pull the pin on the fire extinguisher. ✓ 5) Extinguish the fire. 1033. The nurse is completing medication reconciliation with a client just before discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response? ✓ "We do this to make sure you will be receiving the correct medications once you are at home." 1034. The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply. ✓ Monitor language and tone. ✓ Adopt a "need-to-know" policy. ✓ Be alert to the presence of gossip. ✓ Hold yourself and one another accountable. 1035. A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment should include which parameters? Select all that apply. ✓ The client's vital signs ✓ The client's level of consciousness ✓ The patency of intravenous lines 1036. The nurse has called a client's primary health care provider (HCP) to clarify a medication prescription. The HCP gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time? ✓ Read the prescription back to the HCP after writing it on the prescription sheet. 1037. The nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next? ✓ Stop the IV infusion. 1038. The nurse is preparing to administer 1 mg of hydromorphone, a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct? ✓ Ask a second nurse to witness disposal of the unused portion. 1039. A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased, and the client is still shivering. What should the nurse do next? ✓ Remove the hypothermia blanket and notify the client's health care provider. 1040. The nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which findings noted by the nurse are indicative of impaired circulation? Select all that apply. ✓ Areas of pallor ✓ Decreased movement ✓ Decreased temperature ✓ Reports of pain or tingling 1041. A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? ✓ Encourage the client to use artificial saliva to manage dryness. 1042. The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place and takes which action next? ✓ Activates the fire alarm 1043. A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit? ✓ Approaching the client from the unaffected side 1044. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? ✓ Removing the client from any immediate danger 1045. The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Click on the Question Video button to view a video showing preparation procedures. ✓ Asks the client to swallow while palpating the throat 1046. The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly? Click on the Question Video button to view a video showing preparation procedures. ✓ Makes sure that two fingers can be inserted under the restraint 1047. A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe? ✓ Restraints 1048. The nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair? ✓ Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. 1049. The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety? ✓ Check for tube placement and residual amount at least every 4 hours. 1050. A client is scheduled for insertion of a peripherally inserted central catheter, and the nurse explains the advantages of this catheter. Which statement by the client indicates a need for follow-up? ✓ "It is specifically designed for short-term use." 1051. The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. At which frequency should the nurse plan to check the IV sites of these clients? ✓ Every hour 1052. The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that which occurred? ✓ Phlebitis of the vein 1053. The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? ✓ Sterile 2 × 2 gauze 1054. The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the health care provider (HCP) has prescribed a dose that is twice the amount that the client has reported taking before admission. What is the most appropriate nursing action? ✓ Contact the HCP directly. 1055. The nurse in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first? ✓ Remove the client from the waiting room. 1056. The health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe? ✓ Placing the heating pad under the client 1057. The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do? ✓ Cover the ice pack with a pillowcase and place it on the eye. 1058. A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel to clean up the blood spill is incorrect? ✓ Blots up the spill with a face cloth or cloth towel 1059. At a local school, a community health nurse is providing an educational session on childhood poisoning. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse should include taking which action first if an accidental poisoning occurs? ✓ Call the Poison Control Center. 1060. The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position? ✓ Elevated on one or two pillows 1061. The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action? ✓ Pull back on the tube, and wait until the client is breathing easily. 1062. The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action? ✓ Assess tube placement. 1063. Treatment for a client with bleeding esophageal varices has been unsuccessful, and the health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action? ✓ Place a pair of scissors at the client's bedside. 1064. The nurse is performing discharge teaching for a client with a peripherally inserted central catheter (PICC). Which instructions should the nurse include? Select all that apply. ✓ Wear a MedicAlert tag or bracelet. ✓ Report redness or swelling at the catheter insertion site. ✓ Have a repair kit available in the home for use if needed. ✓ Cover the PICC dressing with plastic when in the shower or bath. 1065. The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical (vocational) nurse, and 2 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? ✓ The client with an abdominal wound requiring frequent wound irrigations 1066. The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? ✓ Democratic 1067. The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the unlicensed assistive personnel (UAP) to implement which action when caring for the client? ✓ Remove the water pitcher from the bedside. 1068. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? ✓ A client who requires assistance with ambulation every 4 hours 1069. The nurse is planning the client assignments for a group of clients and has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the nursing team. Which client would the nurse most appropriately assign to the LPN? ✓ A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion 1070. The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management? ✓ Promotes appropriate use of hospital personnel 1071. The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit? ✓ Autocratic 1072. Laptop computers have been purchased by a community hospital to be used in the nursing units for documentation. The nurse educator at the hospital plans in-service educational sessions regarding the use of the computers and the new documentation system. The nurse educator anticipates some resistance to the use of the computers and should plan to best deal with this difficulty by doing what? ✓ Allowing the nurses extra time to work with the new computer system 1073. The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two unlicensed assistive personnel (UAP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? ✓ A client scheduled for a cardiac catheterization 1074. The home health nurse develops a plan of care for the client. Which actions should the nurse include in the plan as a case manager of the client's care? ✓ Organize, manage, and balance health care services needed for the client. 1075. The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? ✓ Stop administering the enemas. 1076. A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the unlicensed assistive personnel (UAP)? ✓ Orient the client to the hospital surroundings. 1077. A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which action by the LPN requires follow-up by the RN? ✓ The LPN places the client's knee in a slightly externally rotated position. 1078. A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? ✓ "Cushing's syndrome is caused by excessive amounts of cortisol." 1079. The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? ✓ A client requiring frequent temperature measurements 1080. A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the unlicensed assistive personnel (UAP)? Select all that apply. ✓ Collecting a urine specimen from a client ✓ Obtaining frequent oral temperatures on a client ✓ Accompanying a client being discharged to his transportation to home 1081. The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN? ✓ Place the client in a side-lying position. 1082. The nurse manager has involved all staff members in the development of goals and decision making. Which leadership style has the unit manager exercised? ✓ Democratic 1083. The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? ✓ A client on bed rest who requires range-of- motion (ROM) exercises every 4 hours 1084. The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? ✓ Administration of a new oral medication to a client with Alzheimer's disease 1085. The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the unlicensed assistive personnel (UAP)? Select all that apply. ✓ Cleaning a client's dentures ✓ Ambulating a postoperative client ✓ Taking 4:00 p.m. vital signs on clients ✓ Assisting a client with a urinary drainage catheter into a chair 1086. The registered nurse (RN) is planning her client assignments for the day. She has a licensed practical nurse and an unlicensed assistive personnel (UAP) on her team. Which task should the RN delegate to the UAP? ✓ Empty a client's urinary catheter bag. 1087. The nurse is delegating the morning hygienic care of a man to the unlicensed assistive personnel (UAP). In reviewing the assigned tasks, the nurse should instruct the UAP to use an electric razor for which client? ✓ The client with thrombocytopenia related to chemotherapy 1088. The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. ✓ The client receiving continuous oxygen at 2 L/min ✓ The client recovering from Guillain-Barré syndrome ✓ The client on isolation for methicillin- resistant Staphylococcus aureus 1089. The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. ✓ A client needing a bed bath ✓ A client needing to ambulate ✓ A client requiring assistance with feeding ✓ A client needing to have vital signs checked ✓ A client needing to use the bedside commode 1090. The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an unlicensed assistive personnel (UAP)? ✓ Providing distraction for the client by engaging the client in a board game 1091. The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. ✓ A confused older client who requires feeding ✓ A client who requires turning every 2 hours ✓ A client admitted with dehydration who is on strict intake and output ✓ A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day 1092. The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. ✓ Measuring the client's height and weight ✓ Monitoring oral intake and urinary output 1093. The nurse is planning client assignments for the day. Which clients can be safely assigned to unlicensed assistive personnel (UAPs)? Select all that apply. ✓ Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing ✓ Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding 1094. The nurse should instruct the unlicensed assistive personnel (UAP) to avoid the use of a straight razor for which client? ✓ The client taking warfarin 1095. The nurse is developing a client care assignment for a group of unlicensed assistive personnel (UAPs). What is the nurse's first step in planning and assigning clients? ✓ Determine what skills can be delegated. 1096. The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. Which term describing this organizational chart should the vice president employ while talking with the employees? ✓ Flat 1097. The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? ✓ "As the manager, do you assume a passive, nondirective approach?" 1098. The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? ✓ "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 1099. Which tasks should the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. ✓ Urinary catheterization ✓ Endotracheal suctioning ✓ Intramuscular medication administration ✓ Subcutaneous medication administration 1100. The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? ✓ Tertiary level of prevention 1101. The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? ✓ Call the nursing supervisor to activate the agency disaster plan. 1102. The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. ✓ Provide crisis counseling. ✓ Identify and train personnel ✓ Handle inquiries from families 1103. The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. ✓ Flashlight ✓ Supply of batteries ✓ Battery-operated radio ✓ Extra pair of eyeglasses 1104. A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has been losing weight for 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins to cry and tries to eat more. Based on the nurse's actions, the nurse may be accused of which legal tort? ✓ Assault 1105. A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? ✓ "They are nursing care plans and use the steps of the nursing process." 1106. The nurse witnesses an automobile crash on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the crash. Which is accurate regarding the nurse's immunity from this suit? ✓ The Good Samaritan law will protect the nurse. 1107. The nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance during the change process. Which primary technique should the nurse use in implementing this change? ✓ Introduce the change gradually. 1108. The registered nurse (RN) is observing a licensed practical nurse (LPN) who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN should intervene if the RN notes the LPN performing which action? ✓ Elevating the knee gatch on the client's bed 1109. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action? ✓ Massaging the injection site after injection 1110. The nurse employed in a surgical unit in a hospital arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is most appropriate? ✓ Call the nursing supervisor to discuss the request to report to pediatrics. 1111. The nurse is acting in the role of client advocate in which situations? Select all that apply. ✓ Promoting client comfort ✓ Questioning health care provider prescriptions ✓ Supporting a client decision regarding a health care choice 1112. A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? ✓ A postoperative client is discharged home 1 day earlier than expected. 1113. The nurse calls a client's health care provider (HCP) to report that the client, who has heart failure, is demonstrating increased wheezes on lung auscultation and dyspnea. The HCP is in a hurry because of involvement in a critical care situation in the hospital emergency department and gives the nurse a telephone prescription for furosemide. Afterwards, the nurse realizes that the route of the medication is unclear. Which action by the nurse is the most appropriate? ✓ Call the HCP who gave the telephone prescription and clarify the prescription. 1114. The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? ✓ Apply saline-soaked dressings over the medication. 1115. A health care provider (HCP) asks the nurse to discontinue tube feeding in a client who has a terminal condition. The HCP tells the nurse that the request was made by the client's spouse and children. What should the nurse check for first before carrying out the prescription? ✓ Authorization by the family to discontinue the treatment 1116. After initial assessment the nurse determines the need to place a restraint on a client. The client refuses application of the restraint. What is the best nursing action for this client? ✓ Contact the health care provider (HCP). 1117. While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a client. Which is the important information for the nurses to remember when talking about the client? ✓ Talking about clients in public places is a violation of the client's confidentiality. 1118. The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate should indicate to the nurse that there is a need for further teaching? ✓ "I don't think you need to do that." 1119. A woman with left-sided weakness needs assisted living. The woman's family plans to sell her home to pay for assisted living, but the woman refuses to sell because she feels that her family should pay the expenses. What should the nurse do at this time? ✓ Ask the woman to share experiences about the house. 1120. The registered nurse (RN) is beginning a new job in a clinic and attends an orientation session. After the session, another new employee asks the RN to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. Which statement made by the nurse is the most appropriate? ✓ "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." 1121. The community health nurse is working with disaster relief personnel after a hurricane that ruined many homes in the local community. The nurse is working to find housing for the survivors and is organizing counseling services. Which prevention level do the nurse's actions represent? ✓ Tertiary 1122. The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse? ✓ Caregiver 1123. A client refuses to take a medication. Which is the most therapeutic response by the nurse? ✓ "You don't have to take the medication if you don't want to." 1124. The experienced nurse is observing a newly hired graduate nurse count opioids as part of the orientation process. The experienced nurse determines that the newly hired nurse needs further teaching about the procedure for counting opioids when which statement is made? ✓ "If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift." 1125. The nurse is working at a computer in the nurses' station when the charge nurse from another nursing unit approaches and asks about the condition of the client in room 432, stating, "The client is my neighbor and I want to check on her." The nurse should make which most appropriate response? ✓ "I'm sorry, I cannot tell you." 1126. Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply. ✓ "This document is a separate document from my final will." ✓ "This document describes the kind of treatment I want depending on how sick I am." 1127. The nurse suspects that a client is not fully aware of the implications of a procedure and the client is about to sign an informed consent. What action would be most appropriate for the nurse to take? ✓ Inform the HCP that the client does not appear to fully understand the procedure and withhold obtaining the signature. 1128. While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, and I hope she is okay." What is the nurse's best response? ✓ "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients." 1129. A client is scheduled for surgery, and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs further teaching before giving informed consent to the procedure? ✓ "I know my surgeon explained it, but I still don't know why surgery is needed." 1130. The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Which is important information for the nurse to remember? ✓ That an informed consent needs to be obtained from the client 1131. The nurse is caring for a client who has just returned from having a cystoscopy with biopsy. The nurse should intervene if an unlicensed assistive personnel (UAP) is observed taking which action? ✓ Insisting that the client ambulate immediately after the procedure 1132. The nurse is caring for a client who has just returned from having a right-sided renal biopsy. Which action by the unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse? ✓ Positioning the client on the left side 1133. The nurse gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the health care provider to report the occurrence. Which action should the nurse manager anticipate will take place next? ✓ The incident report will be used to review quality of care and determine potential risks. 1134. The nurse discovers a co-worker in the linen closet injecting a medication into the antecubital area. Which most appropriate action should the nurse take? ✓ Call the nursing supervisor. 1135. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response by the nurse is most appropriate? ✓ "I will call the nursing supervisor for assistance regarding your request." 1136. The nurse has made an error in documenting an assessment finding in the client's record. What action should the nurse take to correct the error? ✓ Draw a line through the error, initial and date the line, and then provide the correct information. 1137. The nurse hears a client calling out for help and finds the client lying on the floor. The nurse performs an assessment and assists the client back to bed. The health care provider is notified of the incident, and the nurse completes an incident report. What should the nurse document on the incident report? ✓ The client was found lying on the floor. 1138. A homeless client comes to the emergency department complaining of severe pain in the toes of both feet. On assessment, it is found that all of the toes are black in color and that amputation is necessary. The client refuses the surgery and insists on returning to street living. Which describes the next appropriate action to take? ✓ Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings. 1139. The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse should take which priority action? ✓ Obtain telephone consent from the family member witnessed by 2 authorized individuals. 1140. The nurse manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The nurse manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control during the prior 48 hours. Who should the nurse manager contact next? ✓ Case manager, to determine whether the predicted variance has been negotiated with the health insurer 1141. A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used. ✓ 1) Gather all information relevant to the case ✓ 2) Examine and determine one's own values on the issues. ✓ 3) Verbalize the problem. ✓ 4) Consider possible courses of action. ✓ 5) Negotiate the outcome. ✓ Evaluate the action. [Show More]

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