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NCLEX Fundamentals II 3.18.43 PM, Plus Cardio NCLEX (137 Q&A) and Neurology NCLEX. 328 Q&A. 100% Correct Answers

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NCLEX Fundamentals II 3.18.43 PM A health care provider's prescription reads potassium chloride 20 mEq in 1000 mL normal saline and infuse at 100 mL/hr. The nurse assisting in caring for the client d... etermines that the client will receive how many milliequivalents (mEq) of potassium every hour? Fill in the blank. Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child? . The nurse is assigned to care for an Asian-American client. The nurse develops a plan of care based on which belief? An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder? The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse should make note of which finding to detect an adverse effect of this medication? A client who takes theophylline (Theo-24) for chronic obstructive pulmonary disease (COPD) is seen in the health care clinic. A theophylline level is drawn, and the nurse determines that the client is compliant with the medication regimen if which laboratory result is reported? Review: Therapeutic range of theophylline. The health care provider prescribes ibuprofen (children's Motrin) 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill in the blank. Record your answer using one decimal place. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Fundamental Skills: Medication/IV Calculations Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety Diphenhydramine hydrochloride (Benadryl) 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. What should the nurse determine about the medication dosage? A health care provider's prescription reads triazolam (Halcion), 125 mcg orally at bedtime daily. The medication bottle is labeled triazolam, 0.125-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank. A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea? The nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, which should the nurse avoid to minimize the chance for further injury? The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3– of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and expects to note which? A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications? Refer to chart. View Chart The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply. The health care provider prescribes a three-way bladder irrigation of normal saline to be infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank. The health care provider prescribes a three-way bladder irrigation of normal saline to be infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank. The nurse is preparing a session regarding nutrition for a group of culturally diverse pregnant women. The nurse determines that the priority nursing intervention includes which action? The health care provider's prescription reads "levothyroxine (Synthroid), 150 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client? Fill in the blank. Record your answer using one decimal place. A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag? The nurse determines that an adult male client admitted with dehydration and a hematocrit level of 56% has received adequate fluid volume replacement if which repeat hematocrit level is noted? A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which will be prescribed? A client having preadmission testing before surgery has blood drawn for the determination of serum electrolyte levels. The nurse determines that which result warrants a call to the health care provider by the nurse? The nurse determines that sodium polystyrene sulfonate (Kayexalate) has been effective in a client if which laboratory result is noted? A client with a history of cardiac disease is scheduled for a dose of furosemide (Lasix). Which serum potassium level warrants a call to the health care provider by the nurse before administering the furosemide?. A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. Which action by the nurse is most appropriate after reading this report? The nurse is reviewing the serum magnesium results for a group of clients. Which results warrant a call to the health care provider by the nurse? Select all that apply. . A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem? A client with a seizure disorder is taking phenytoin (Dilantin). A sample for a serum phenytoin level is drawn, and the nurse determines that the next dose of the medication may be administered if which laboratory result is noted? A client was diagnosed with acute pancreatitis 10 days ago. The nurse interprets that the episode of acute pancreatitis is fully resolved if the serum lipase level drops to which value? A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. How should the nurse correctly interpret these results? A client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely the result of which factor in the client's history? A client is a lacto-vegetarian. Which food item should the nurse remove from the tray? A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin? Rationale: Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? The nurse is caring for a client with a health care–associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure? The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should assist the client to which position? The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? The nurse is preparing to administer medication through a nasogastric (NG) tube that is connected to suction. Which indicates the accurate procedure for medication administration? Which laboratory result would verify the diagnosis of bacterial meningitis? The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus(MRSA). Which precautions should the nurse institute during the care of the client The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure? A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. Which position should the nurse assist the client into for this procedure? The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care? Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia. The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take? Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L? The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply. The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply. The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which sign does the nurse expect to note in the client, based on this magnesium level? The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL? The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food item contains the least amount of phosphorus? The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. Which signs should the nurse expect to note during the data collection? Select all that apply. A client with diabetes mellitus has a glycosylated hemoglobin A (HbA1c) level of 8%. Which instruction does the nurse plan to reinforce to the client based on this test result? The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse knows that neutropenic precautions will be implemented if the client has which white blood cell (WBC) count? The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? Select all that apply. Diphenhydramine hydrochloride (Benadryl), 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. Which conclusion should the nurse infer? A pediatric client with a ventricular septal defect repair is placed on a maintenance dose of digoxin (Lanoxin). The safe dose is 0.03 mg/kg/day, and the client's weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. How much digoxin should the nurse administer to the client at each dose? The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take? The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value? The nurse provides dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse tells the client that the fruit highest in potassium is which selection? Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia? The registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which supply obtained by the LPN indicates a need for further teachingregarding this procedure? The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of the tube, the nurse should assist the client to which position? The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The health care provider has prescribed an amount of 100 mL/hr. How much formula should the nurse plan to add to fill the feeding bag? The nurse is preparing to suction a client through a tracheostomy tube. The nurse should avoid which action when performing this procedure? The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result should indicate to the nurse that the surgery might be postponed? The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise should be used as tools to keep the total cholesterol level under at least which level? A client is suspected of having a myocardial infarction. The nurse should expect elevations in which isoenzyme value reported with the creatine kinase (CK) level? Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the health care provider (HCP)? Select all that apply. A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse determines that the client may not be compliant with medication therapy if which result is obtained? The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most alike to which value? A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? The nurse is instructing a client on how to decrease the intake of magnesium in the diet. The nurse tells the client that which food item contains the least amount of magnesium? The nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse tells the client that which food provides the least amount of potassium? Renal/Reproductive The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which are functions of amniotic fluid? Select all that apply. Allows for fetal movement Is a measure of kidney function Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item? The nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse should monitor for which adverse effects of this medication? Select all that apply. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which is noted on data collection? Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs? Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which condition? A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should question administration of the medication if which condition is documented in the client's medical history? The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student makes which statement? A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, which medication does the nurse anticipate will be prescribed? The nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should discontinue the oxytocin infusion and notify the registered nurse if which is noted on data collection of the client? The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply. A client has epididymitis as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent a recurrence. The nurse determines that the client needs further teachingif the client states the intention to do which? The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine if the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom? A client newly diagnosed with chronic kidney disease has recently begun hemodialysis. Which are signs/symptoms of disequilibrium syndrome? A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate? A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which signs/symptoms of this disorder? The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this disorder? The nurse is reviewing the client's record and notes that the health care provider has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. A client is scheduled for intravenous pyelography (IVP). Which priority nursing action should the nurse take? After a renal biopsy, the client complains of pain at the biopsy site, which radiates to the front of the abdomen. Which would this indicate? The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply. The nurse is collecting data on a newly admitted client with a diagnosis of bladder cancer. Which sign/symptom should be noted first? A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome? A client with prostatitis resulting from kidney infection has received instructions on management of the condition at home and prevention of recurrence. Which statement indicates that the client understood the instructions? The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of the infection. Which sign/symptom should occur first? The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? A sulfonamide is prescribed for a client with a urinary tract infection. On review of the client's record, the nurse notes that the client is taking warfarin sodium (Coumadin) daily. Which prescription should the nurse anticipate for this client? Methenamine (Urex), a urinary antiseptic, is prescribed for the client. The nurse reviews the client's medical record and should contact the health care provider regarding which documented finding to verify the prescription? Refer to chart. Trimethoprim-sulfamethoxazole (TMP-SMZ) is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy? Phenazopyridine hydrochloride (Pyridium) is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which should the nurse reinforce to the client? Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication? The nurse who is administering bethanechol chloride (Urecholine) is monitoring for acute toxicity associated with the medication. The nurse should check the client for which sign of toxicity? Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? After kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions? The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions? The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process? The nurse is inspecting the stoma of a client after creation of an ureterostomy. Which appearance should the nurse expect to note? The nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic kidney disease. Which finding indicates that the fistula is patent? A client newly diagnosed with renal failure will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of risk for which complication? A client is diagnosed with polycystic kidney disease, and the nurse provides information to the client about the treatment plan. The nurse determines that the client needs further teaching if the client states that which component is part of the treatment plan? The client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). When should the nurse plan to administer this medication? The nurse is caring for a client who had a renal biopsy. Which interventions should the nurse include in the plan of care for the client after this procedure? Select all that apply. A client is admitted to the emergency department following a fall from a horse. The health care provider (HCP) prescribes the insertion of an indwelling urinary catheter. The nurse notes blood at the urinary meatus while preparing for the procedure. Which action should the nurse take? A male client has a tentative diagnosis of urethritis. The nurse collects data from the client knowing that which are signs/symptoms of this disorder? A male client 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 a contraction of the infection during care. Which instruction should the nurse give the UAP? The nurse is caring for a client with epididymitis. The nurse anticipates noting which group of findings on data collection? A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication? A client with chronic kidney disease is receiving epoetin alfa (Epogen, Procrit). Which laboratory result should indicate a therapeutic effect of the medication? The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of an arteriovenous (AV) fistula. Which statement by the client indicates an understanding of the instructions? Methylergonovine is prescribed for a client with postpartum hemorrhage caused by uterine atony. Before administering the medication the nurse checks which important client parameter? The licensed practical nurse (LPN) is assisting a school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is which? The maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which hormone(s) identified by the student indicates an understanding of the hormones produced by this endocrine gland? The maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phase stated by the nursing student indicates a need for further teaching in this area? The nurse prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client with chronic kidney disease for which laboratory abnormality? The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply. A client has been examined in the clinic and has been diagnosed with endometriosis. The client asks the nurse to describe this condition. Which description of endometriosis by the nurse is accurate? The nurse is assisting in conducting a teaching session with a group of adolescents. The nurse tells the adolescents that the hormone that induces the growth of pubic and axillary hair at puberty is which? Which statement made by the nursing student demonstrates an understanding of the hormone oxytocin? The nurse is collecting data from a client who is suspected of having mittelschmerz. Which should the nurse expect to note? The nurse has reinforced instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client makes which statement? The nurse is reviewing the health record of a client who is suspected of having mittelschmerz. Which should the nurse expect to note documented in the client's record? An alkaline-ash diet is prescribed for a client with renal calculi. Which diet menu does the nurse advise the client to select? The nurse is assisting in planning a diet for a client with acute kidney injury (AKI). The nurse plans to restrict which dietary component from this client's diet? A client who suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse plans to monitor this particular client carefully for signs of which complication? The nurse is caring for a client with kidney failure. The serum phosphate level is reported as 7 mg/dL. Which medication should the nurse plan to administer as prescribed to the client? A client is seen in the health care clinic with a diagnosis of mild anemia. The anemia is believed to be a result of the menstrual period. The woman asks the nurse how much blood is lost during a menstrual period. Which is a normal amount of blood loss during a menstrual period that the nurse should compare with the client's loss? A nursing instructor asks a nursing student to describe Montgomery's tubercles of the breast. Which response by the student indicates an understanding of this anatomical structure? A maternity nurse is providing an in-service educational session to nursing students regarding the process of conception. The nurse determines that a nursing student understands this process if the student states that fertilization of a mature ovum occurs in which areas? A nursing student is asked to describe the corpus of the uterus. Which response by the student indicates an understanding of the anatomy of the uterus? A client hospitalized with urolithiasis has a sudden significant decrease in urine output. The nurse should perform which action? The nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse notifies the registered nurse and plans to take which action? The postpartum nurse is caring for a client following a cesarean birth who received epidural analgesia. The client is lethargic and is exhibiting signs of respiratory depression. The nurse suspects that the respiratory depression is caused by the epidural analgesia. The nurse notifies the registered nurse immediately and prepares the client for the administration of which medication? The nursing student is assigned to care for a 30-week gestational woman who is admitted to the maternity unit in preterm labor. Betamethasone is prescribed to be administered to the mother. The nursing instructor asks the student about the purpose of the medication. Which statement by the student indicates an understanding of the purpose of this medication? The nurse is caring for a hospitalized client following cystoscopy and is monitoring for signs of complications associated with the procedure. Which result noted in the first few hours following the procedure indicates the need to notify the registered nurse? The nurse is admitting a client to the nursing unit who has returned from the postanesthesia care unit following prostatectomy. The client has a three-way Foley catheter with continuous bladder irrigation. The nurse should maintain the flow rate of the continuous bladder infusion to maintain which urine output characteristic? The nurse is providing dietary instructions to a client with renal calculi, and the laboratory analysis has revealed that the calculus is composed of uric acid. The nurse tells the client that it would be helpful to make which dietary changes? In reviewing the admission assessment data and health care provider's prescriptions for a client with peptic ulcer disease, the nurse notes that the client has a history of renal disease. Based on this data, the nurse determines that which antacid should be prescribed for this client? A client with a history of prostatic hypertrophy has purchased the over-the-counter medication, diphenhydramine (Benadryl), to treat symptoms of a runny nose. The nurse explains to the client that this medication combined with prostatic hypertrophy could cause exacerbation of which symptom? Bethanechol (Urecholine) is prescribed for the client with urinary retention, and an injectable form of bethanechol is available for use as prescribed. The nurse informs the client of the health care provider's prescription, knowing that the medication will be administered by which route? A client has undergone a transurethral resection of the prostate (TURP) a few hours ago to treat symptoms of benign prostatic hypertrophy. The nurse notes bright red blood and clots in the urinary catheter drainage bag. Which response should be the nurse's initial action? Magnesium sulfate is prescribed for a client with severe preeclampsia. Which statement by the student nurse supports the need for further teaching regarding the action of this medication? A client with severe preeclampsia is receiving magnesium sulfate by intravenous infusion. The nurse reviews the laboratory results, knowing that which value is a therapeutic magnesium level? A client diagnosed with severe preeclampsia is on magnesium sulfate by continuous intravenous infusion. Which finding suggests to the nurse that the next dose of this medication should be held? A client has been prescribed allopurinol (Zyloprim). The nurse reinforces which information concerning the administration of the medication? The nurse is reinforcing dietary instructions to a client who is currently prescribed probenecid (Benemid). Which food should the nurse encourage the client to continue to eat? The nurse is caring for a client diagnosed with Parkinson's disease who is prescribed benztropine mesylate (Cogentin) daily. The nurse reinforces instructions to both the client and the spouse regarding the side effects of this medication and the need to report which side effect if it occurs? The nurse is providing instructions to the client regarding the complications of peritoneal dialysis. The nurse instructs the client that which symptom is likely associated with the onset of peritonitis? A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The nurse appropriately asks which question first? A client complains of leaking urine whenever she sneezes, coughs, or laughs. The nurse recognizes that this report is consistent with which type of incontinence? The nurse is caring for a client in preterm labor who is receiving terbutaline sulfate to stop uterine activity. During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication? The nurse documents that the urine collected from a client diagnosed with early stage polycystic kidney disease is dilute with a low-specific gravity. Based on this documentation, which specific gravity result was likely present? The nurse is reinforcing instructions to a client with glaucoma receiving acetazolamide (Diamox) daily. Which statement by the client indicates an understanding of the adverse effects related to the medication? The nurse is assisting a client with cystitis to select foods that are appropriate for an acid-ash diet. The nurse encourages the client to eat which food? The nurse is assigned to care for a client who has just returned to the nursing unit after having hemodialysis for the first time. The nurse monitors the client carefully for which signs and symptoms of disequilibrium syndrome? A client is seen in the health care clinic and acute pyelonephritis is suspected. The nurse reviews the client's record and should expect to note which associated signs and symptoms documented? Select all that apply. The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which client? Which conditions places the client at risk for developing acute postrenal failure? The nurse is assessing a client with suspected acute kidney injury. Which finding would support a diagnosis of acute intrarenal failure? A client diagnosed with chronic kidney disease is being treated at home with continuous ambulatory peritoneal dialysis. The client notes that there is a decrease in the catheter outflow following the prescribed 6-hour dwell time and calls the nurse to report this occurrence. The nurse should reinforce instructing the client to take which action? Which statements indicate an understanding of the necessary dietary modifications of a client diagnosed with chronic kidney disease? Select all that apply. The nurse is assigned to care for a client who has returned to the nursing unit following a left nephrectomy. The nurse places the highest priorityon monitoring which data? A client with acute kidney injury (AKI) has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse evaluates this therapy as effective if which value is noted on follow-up laboratory testing? The nurse is admitting a client with chronic kidney disease (CKD) to the nursing unit. The nurse monitors the client for which frequent cardiovascular sign that occurs in CKD? The nurse is assisting in preparing a plan of care for a client who will be receiving a calcium antagonist to prevent preterm delivery. Which action does the nurse include in the plan of care for the client to detect a side effect of the medication? The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure? The nurse is urging a client to cough and deep breathe after a nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is likely a result of which contributing factor? A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further teachingif the client makes which statement? The nurse notes that a client's urinalysis report contains a notation of positive red blood cells (RBCs). The nurse interprets that this finding is unrelated to which item that is part of the client's medical record? A client with acute glomerulonephritis had a urinalysis sent to the laboratory. The report reveals that there is hematuria and proteinuria in the urine. The nurse interprets that these results are which? A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. Which information about this procedure should the nurse give to the client? The nurse is assisting in monitoring a preterm infant in the neonatal intensive care unit who received surfactant (Infasurf). The nurse monitors for which desired therapeutic outcome of this medication? The nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists to prepare which medications that will be prescribed to be given within the first hour of life? Select all that apply. The client with diabetes mellitus receiving peritoneal dialysis asks the nurse why it is important to leave the dialysate infused only for a specific amount of time. The nurse responds that not adhering to the dwell time can increase the risk of the client experiencing which complication? The nurse is reinforcing dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states the intention to do which action? A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder? The nurse is collecting data from a client with epididymitis. The nurse should expect to note which signs and symptoms of this problem? A client arrives at the ambulatory care clinic with low abdominal pain. A routine urine specimen reveals hematuria. The client does not have a fever. The nurse should next ask the client about a history of which condition? A client's kidneys are retaining greater amounts of sodium. The nurse anticipates that the kidneys are also retaining greater amounts of which other substances? The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how this could happen. The nurse plans to base a response in part on the fact that which statement is true? The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which clients? An adolescent is admitted to the hospital with complaints of lower right abdominal pain. The health care provider prescribes laboratory tests to rule out ectopic pregnancy rather than appendicitis. Which is most significant in ruling out an ectopic pregnancy? A male client has a history of urinary tract infections due to urinary retention. Which intervention should the nurse implement to decrease the risk of infection? The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. Which time of the month should the nurse tell the client to perform breast self-examination? The nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for a renal biopsy, when other tests such as computed tomography (CT) and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that a renal biopsy serves which purpose? The nurse is assisting in planning a teaching session with a client diagnosed with urethritis caused by infection with Chlamydia. The nurse should plan to include which point in the teaching session? A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states which? A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia (BPH), the nurse questions the client about use of which medication? A client who had a prostatectomy has learned perineal exercises to gain control of the urinary sphincter. The nurse determines that the client needs further teaching if the client states that he will perform which action as part of these exercises? The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which reaction? A urinary analgesic is prescribed for a client with a urinary tract infection. When should the nurse tell the client that it is best to take the medication? Bethanechol chloride (Urecholine) is prescribed for a client. When should the nurse tell the client to take the medication? Propantheline bromide (Pro-Banthine) is prescribed for a client with bladder spasms. Which disorder, noted in the client's record, alerts the nurse to question the prescription for this medication? Aluminum hydroxide is prescribed for the client with chronic kidney disease (CKD). When should the nurse instruct the client to take this medication? The nurse is reinforcing dietary instructions to a client with renal calculi who must learn to eat an alkaline-ash diet. The nurse determines that the client has properly understood the information presented if the client chooses which selection from a diet menu? The nurse must ambulate a client who has a nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely and effectively by performing which action? A long-term care nurse notes that a female client has leakage of urine when sneezing, coughing, or laughing. The nurse reports that this client has which type of incontinence? The nurse caring for a client taking tamsulosin (Flomax) determines that which finding indicates the need for follow-up? A client has just undergone renal biopsy. In planning care for this client, the nurse should avoid which intervention? The nurse has a prescription to collect a 24-hour urine specimen from a client. The unlicensed assistive personnel (UAP) has been instructed on the collection technique. Which action by the UAP demonstrates the UAP needs further teaching? The nurse is preparing a client scheduled for an intravenous pyelogram (IVP). The nurse should take which important action before the test? A female client has a prescription for a clean-catch urine culture. After providing a sterile specimen cup to the client, the nurse should give which instruction so that the specimen is collected properly? A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which signs/symptoms after the dialysis treatment? The nurse is assisting a client who is new to a low-potassium diet to select food items from the menu. Which food item is lowest in potassium and should be recommended to the client on this dietary restriction? A client is admitted to the surgical nursing unit following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and output is light cherry colored. The blood pressure is 134/82 mm Hg, the pulse is 84 beats per minute, and the client is afebrile with a respiratory rate of 18 breaths per minute. The licensed practical nurse (LPN) assisting in caring for the client collects assessment data 1 hour after admission to the nursing unit. The LPN notifies the registered nurse (RN) if which is noted on data collection? A client with acute glomerulonephritis is admitted to the nursing unit. The nurse should plan to do which action immediately on admission? A client with a urinary tract infection with dysuria is given a prescription for phenazopyridine hydrochloride (Pyridium) for symptom relief. Which should the nurse reinforce instructing the client about this medication? The nurse is preparing a subcutaneous dose of bethanechol chloride (Urecholine) prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart? The nurse suspects the client has a urinary tract infection (UTI). Which signs/symptoms suggest a UTI? Select all that apply. A client with end stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery? Select all that apply. A client contacts the health care provider's office to report she is not feeling well, has burning with urination, and suspects she may have a urinary tract infection. The nurse instructs the client to collect a urine specimen for testing. Which urinalysis findings indicate the presence of a urinary tract infection? Select all that apply. A client with end stage kidney disease (ESKD) begins peritoneal dialysis. The nurse observes for which signs/symptoms indicating peritonitis? Select all that apply. A client who underwent a kidney transplant 6 months earlier is seen in the clinic for a routine monthly appointment. The nurse reviews how the client has been doing and observes for signs/symptoms of acute rejection. Which signs/symptoms suggest acute rejection of the transplanted kidney? Select all that apply. The nurse is speaking with a client who underwent a minimally invasive procedure treatment for recurrent urolithiasis. Which instructions are appropriate to reinforce in the teaching plan? Select all that apply. A client, on the waiting list for a renal transplant, receives a hemodialysis treatment. Which findings indicate to the nurse that the treatment has been effective? Select all that apply. Which observations by the nurse caring for clients on a hospital medical-surgical unit should be immediately reported to the health care provider? Select all that apply. A client tells the nurse she completed an educational program to manage her stress incontinence but is now discouraged. Which information from the client indicates the need for further teaching? Select all that apply. A client, who had experienced significant blood loss in an automobile crash, was admitted to the hospital 2 days earlier. The nurse observes the client for which signs/symptoms that indicate acute kidney injury (AKI)? Select all that apply. The nurse is evaluating the data results of a client with sepsis and acute kidney injury with related azotemia and oliguria. Which are the primary features of azotemia and oliguria? Select all that apply. The nurse is caring for a 58-year-old client with renal failure who is on peritoneal dialysis. Which finding is considered most important by the nurse, requiring health care provider notification? Refer to chart. The nurse is caring for a client who received a recent kidney transplant. Besides actual rejection of the transplant, which are some of the most important complications this client is at risk for? Select all that apply. The nurse is evaluating the assessment of a client's arteriovenous fistula being used for hemodialysis. Which findings would prompt the nurse to notify the health care provider immediately? Select all that apply. The nurse is caring for a hemodialysis client who has been receiving treatment for several years and is not a candidate for kidney transplant. The nurse knows that the majority of deaths of hemodialysis clients are related to which causes? Select all that apply. The nurse is caring for a client with a possible ectopic pregnancy. The nurse should perform the following actions in which priority order? Arrange the actions in the order they should be performed. All options must be used. Prepare the client for ultrasound. Assess the client for signs of increased pain or vaginal bleeding. Assess the emotional state of the client. Obtain a urine specimen. The nurse in a women's health clinic is reinforcing instructions to a client that is being treated for pelvic inflammatory disease (PID). Which information would be essential for the nurse to reinforce before discharge? Select all that apply. The nurse at an outpatient cardiology clinic is reviewing the medical history of a 48-year-old man during a routine exam. The client is complaining of the inability to maintain an erection and asks the nurse what could be causing it. Which information should the nurse include as possible contributing factors to his erectile dysfunction? Select all that apply. The nurse is caring for a female 45-year-old client. The client has 3 healthy children, all born via spontaneous vaginal birth. The client has been diagnosed with mild uterine prolapse and asks the nurse what she can do to prevent further prolapse. The nurse should include which instruction in her teaching? Select all that apply. . The nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student makes which statement? A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse should take which priorityprecaution, knowing that bleeding is a potential complication? Cardio NCLEX 1. The nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse should plan to maintain bed rest for this client in which position? - 2. A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which? 3. The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 4. A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The 5. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 6. The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 7. The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 8. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? 9. A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? 10. The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? 11. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? 12. The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 13. The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? 14. A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which? 15. A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 16. A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? 17. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the nurse best describe this type of anginal pain? 18. The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? 19. An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best 20. A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 21. A client is scheduled for a dipyridamole thallium scan. The nurse should check to make sure that the client has not consumed which substance before the procedure? 22. An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem? 23. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 24. The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? 25. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? 26. A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? 27. The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? 28. The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. . 29. A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level? 30. A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first? 31. The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? 32. A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? 33. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 34. A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? 35. The nurse finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"? 36. In order to assess the dorsalis pedis pulse of a client diagnosed with arterial vascular disease, the nurse palpates which anatomical location? Refer to figure. 37. The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? 38. A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first? 39. The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? 40. When preparing a client for a pericardiocentesis, which position does the nurse place the client in? For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? 41. The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? 42. The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health? 43. The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? 44. The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which information? 45. The licensed practical nurse (LPN) is assisting in 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 registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? 46. A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? 47. The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? 48. The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? 49. The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 50. The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? 51. The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? 52. While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? 53. The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? 54. A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing which type of angina? 55. The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching? 56. The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? 57. The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? 58. The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? 59. A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? 60. A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted? 61. A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? 62. The nurse is providing discharge teaching for a post–myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? 63. The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? 64. An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? 65. The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client? 66. An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission? 67. Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin? 68. The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate? 69. The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan 70. The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided? 71. A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? 72. A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems? 73. The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted? 74. The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal? 75. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action? 76. The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside? 77. The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? 78. A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? 79. The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next? 80. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action? 81. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client? 82. The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure? 83. The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? 84. A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? 85. The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next? 86. A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact? 87. The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment? 88. A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time? 89. A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check which? 90. A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response? 91. The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which? 92. A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms? 93. A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure? 94. A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the health care provider to write a prescription for the client to remain on bed rest. In which position should the bed be positioned? 95. The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? 96. A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure? 97. A client, who is 36 hours post–myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made? 98. The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner 99. A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? 100. The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? 101. The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe? 102. The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement? - "A daily half-mile–long brisk walk generally helps people bounce back more quickly and provides more of a sense of control." 103. The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? 104. The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement? 105. The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities? 106. A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home? 107. A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client? 108. The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? 109. A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client? 110. A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action? 111. A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia? 112. The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure. 113. The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client? 114. The nurse is using a stethoscope to listen to the client's heart and hears this sound. (Refer to audio.) To assist in identifying the sound, the nurse should take which initial and best action? 115. The nurse is caring for a client who has a malignant lung neoplasm and has developed cardiopulmonary complications. On auscultation, the nurse hears these breath sounds over the left lower sternal border (over the apical area) and interprets the sounds as which? (Refer to audio.) 116. The nurse is auscultating a client's heart sounds and hears these sounds. (Refer to audio.) The nurse identifies these as being produced during which phase of the cardiac cycle? 117. A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way? 118. A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? 119. A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? 120. A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication? 121. A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active? 122. The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development? 123. A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? 124. The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client? 125. A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? 126. The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu? 127. The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? 128. The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason? 129. A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? 130. The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 131. The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. 132. The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. 133. A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. 134. The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply. 135. The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply. 136. The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 137. The nurse is caring for a client in the cardiac care unit with heart disease. The nurse knows that the direction of blood flows through the heart and lungs in which order? Please arrange the blood flow in the direction of flow. All options must be used. Neurology NCLEX 1. The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions? 2. The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed? 3. The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures. 4. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? 5. Which intervention should be implemented for the older client with presbycusis who has a hearing loss? 6. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. 7. The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? 8. The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? 9. The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? 10. A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? 11. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? 12. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? 13. The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? Report the finding to the registered nurse (RN). 14. The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? 15. The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? 16. A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? 17. The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which? 18. A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo? 19. The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client? 20. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? 21. Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? 22. The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? 23. In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which? . 24. The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which? 25. The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? 26. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? 27. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. 28. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint? 29. Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? 30. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which? 31. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. 32. The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? 33. The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 34. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? 35. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? 36. The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? 37. The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? 38. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? 39. The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? 40. The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 41. The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? 42. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? 43. The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? 44. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. . 45. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? 46. The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? 47. The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination? 48. A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear? 49. The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder? 50. The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching? 51. The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? "I should turn the hearing aid off after removing it from my ear." 52. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted? 15 mm Hg 53. The nurse is assisting in developing a plan of care for the client scheduled for cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery? Sensory perceptual alteration 54. The nurse is reviewing the health record of a client diagnosed with a cataract. The initial sign/symptom that the nurse should expect to note in the early stages of cataract formation is which? Blurred vision 55. The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? On the nonoperative side 56. During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action should the nurse implement? Report the client's complaints. 57. The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating? Drowsiness 58. The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? Maintaining the head of the bed at 15 degrees 59. The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? Restrain the client's limbs. 60. The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? Within the client's reach, on the left side 61. The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? Remind the client to turn the head to scan the lost visual field. 62. A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? Omitted doses of medication 63. A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? Encourage and praise perseverance in exercising and performing ADL. 64. The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? "I will try to eat my food either very warm or very cold." 65. A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Provide a clear path for ambulation without obstacles. 66. The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching? "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye." 67. The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume? Sugar-free Jell-O 68. The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome? The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac. 69. A clinic nurse notes that following several eye examinations the health care provider has documented a diagnosis of legal blindness in the client's chart. Which should the nurse expect to note documented as the result of the Snellen chart test? 20/200 vision 70. The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed? A mydriatic medication 71. A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions? "I will wear my eye shield at night and my glasses during the day." 72. A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." 73. A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye 74. The nurse should check for vision loss in a client with which condition? Diabetes mellitus 75. The nurse is assisting the health care provider with performing a Weber tuning fork test on a client. What does this test assess for? Hearing loss 76. The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions? "I will take stool softeners as prescribed by my doctor." 77. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery? Cranial nerve VII, facial nerve 78. The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Bloody or clear drainage from the auditory canal 79. The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease? Inner ear 80. Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client? "A hearing aid may improve your hearing." 81. The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss? "The attack leaves a hearing loss in the involved ear." 82. The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question? The administration of a vasoconstrictor 83. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching? "I need to avoid air travel for at least 6 months." 84. The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client? "You need to avoid air travel." 85. A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client? "Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery." 86. A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? Walker 87. The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? Encouraging multiple visitors at one time 88. A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration? Establishing a toileting schedule 89. The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? Allergy to pollen 90. A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family? Encouraging the client to stand unassisted on the leg 91. The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure? Allergy to iodine or shellfish 92. A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Prosthetic valve replacement 93. A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure? "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure." 94. The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? Explaining equipment and procedures on an ongoing basis 95. The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? Making sure not to suction for longer than 30 seconds 96. The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use? Skin breakdown 97. The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? Hypothalamus 98. A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? "I can resume a full activity level immediately." 99. The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? It is possible the client can hear the family. 100. The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply. Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep 101. The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine? Codeine does not alter respirations or mask neurological signs as do other opioids. 102. The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching? "I will not hear sounds clearly unless they are loud." 103. The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? Indicates that facial puffiness will be a permanent problem 104. A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? Acknowledge the client's anger and continue to encourage participation in care. 105. A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this? Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. 106. A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity? Doing active range of motion to finger joints 107. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which? Wear the patch continuously, alternating eyes each day. 108. The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? Moving the client quickly as one unit 109. The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important? Client's diet in the 2 hours preceding seizure activity 110. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety? Putting a padded tongue blade at the head of the bed 111. The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment? "Good oral hygiene is needed, including brushing and flossing." 112. A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action? Giving the client thin liquids 113. The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? Completing the sentences that the client cannot finish 114. A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process? 115. A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply. 116. The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? 117. The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statements? 118. A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where? 119. The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? 120. An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings? Red blood cells 121. The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting which? Opisthotonos 122. An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 am. The nurse should first determine which about the client? 123. An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation? 124. A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which? 125. The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information? disease. 126. The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which? 127. The nurse overhears the term sundowning used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. Of which diagnosis is sundowning a symptom? 128. The nurse has reinforced discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further teaching if the client states which? 129. A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement? 130. A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observation? 131. An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF? 132. A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder? 133. The nurse is preparing to reinforce instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on which treatment goal? 134. The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client? 135. The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching? 136. A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record? 137. Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching? 138. A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement? 139. The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching? 140. The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom? 141. The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? 142. The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action? 143. A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client? 144. A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action? 145. A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first? 146. A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action? 147. The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? 148. The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching? 149. The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? 150. The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure. 151. The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? 152. The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply. 153. The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? 154. The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? 155. The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristic of this disease? 156. The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. 157. The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action? 158. The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement? 159. The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply. 160. A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? 161. While at home, the nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye? . 162. A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially? 163. The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse? 164. Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"? 165. Which statement by the nurse indicates an understanding of the diagnosis of presbycusis? 166. The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet? 167. The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention? 168. A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce? 169. The nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching? 170. When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response? 171. Which information will the nurse reinforce to the client scheduled for a lumbar puncture? 172. The nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test? 173. Which data collection finding supports the possible diagnosis of Bell's palsy? 174. The nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question? 175. A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up? 176. A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? 177. A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as indicative of which result? 178. The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to perform which action? 179. The nurse is assisting to perform a Romberg test on a client being seen in the clinic. The nurse performs this test to make which determination? 180. A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion? 181. The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check which client ability? 182. The nurse in a health care clinic is assisting to test the client for accommodation. The nurse should ask the client to perform which initial action? 183. The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis? 184. The nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which criterion as the critical index of central nervous system (CNS) dysfunction? 185. The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP? 186. Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action? 187. Which sign/symptom is observed in the clonic phase of a seizure? 188. The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply. 189. The nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which is a characteristic of early Alzheimer's disease? 190. The clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis? 191. The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented early symptom supports this diagnosis? 192. The nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis? 193. The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test should be prescribed to confirm this diagnosis? 194. The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which question? 195. The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which sign/symptom is considered a primary symptom of this syndrome? 196. A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which nursing action in the plan? 197. The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination? 198. The nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing which is a characteristic of anosognosia? 199. The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? 200. The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan? 201. The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action? 202. Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement? 203. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? 204. The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client? 205. A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action? 206. A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate? 207. A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action? 208. The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question? 209. The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching? 210. The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action? 211. A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? 212. The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions? 213. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result? 214. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result? 215. The nurse is assisting a health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result? 216. A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test? 217. A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply. 218. A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response? 219. The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply. 220. The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity? 221. The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching? 222. A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? 223. A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. When the client asks the nurse how this medication lowers intraocular pressure, which information does the nurse tell the client? 224. The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when the client makes which statement? 225. The nurse is preparing to instill an otic solution into the adult client's right ear. The nurse should include which action while performing this procedure? Select all that apply. 226. A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder? 227. Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client? 228. A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client? 229. A client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which activity to prevent barotrauma during takeoff and landing? Select all that apply. 230. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the health care provider? 231. An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history? 232. A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate? 233. When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse should provide the client with which instruction? 234. A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works effectively if which guideline is followed? 235. The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? 236. A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the health care provider's explanation of the disorder. The nurse should offer the client which explanation? 237. The nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to follow which practice? 238. A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect? Select all that apply. 239. The nurse is collecting neurological data on a poststroke adult client. Which technique should the nurse perform to adequately check proprioception? 240. After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention? 241. The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply. 242. The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. 243. A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem? 244. The nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique should the nurse expect to be used to elicit this sign? 245. The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock? 246. The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which? A decline in the level of consciousness 247. The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client should the nurse report immediately? The client vomits. 248. The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? Foot drop 249. A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? "I will bend at the waist, keeping the halo vest straight to pick up items." 250. The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which intervention does the nurse document in the plan as the priority nursing intervention for this client? Monitor urine output. 251. The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates the client understands the discharge instructions? "I need to call the doctor if I develop frequent swallowing or postnasal drip." 252. The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record? Positive Romberg's test 253. A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply. Tachycardia Photophobia Red, macular rash Positive Kernig's sign 254. The nurse is reinforcing discharge instructions to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further teaching if the client makes which statement? "I can lie on my right side." 255. The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included? Myringotomy 256. The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information? Safety 257. The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply. Tonometry Visual field check 258. A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply. Visual and hearing disturbances Ascending symmetrical muscle weakness 259. The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care? Place an eye patch over the affected eye. 260. The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client? Increase fluids and take a stool softener daily. 261. The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present? Swelling behind the ear 262. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor? Cholinergic miotic agents 263. A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse should perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used. Warm the prescribed solution to body temperature (95° F to 105° F). Have the client sit up holding an emesis basin under the ear to be irrigated with a drape under the basin. Straighten the external canal of an adult by pulling the auricle up and back. Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. Direct the solution toward the top of the canal in a steady stream, not toward the eardrum. 264. A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma? "I need to take my eye drops for the rest of my life." 265. The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client? The UAP speaks directly into the impaired ear. 266. A clinic nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? "I should turn the hearing aid off after removing it from my ear." 267. The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder? Congested cough and coarse rhonchi heard during auscultation 268. The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors? Have the client express the feelings in writing. 269. A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which? Higher than normal, supporting the diagnosis of Guillain-Barré 270. A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication? The client complains of a headache, and the blood pressure is elevated. 271. The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? Areflexia below the level of injury 272. A client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior should serve as a basis for planning nursing care? The client is reacting to loss of control. 273. A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities? Break down activities into small steps. 274. The nurse is caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that which definition describes decerebrate posturing? The extension of the extremities and pronation of the arms 275. A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, which action should the nurse take? Notify the registered nurse. 276. The nurse is planning care for a client with Bell's palsy. Which measure should be included in the plan? Instill artificial tears and wear a patch over the affected eye at night. 277. A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition. It is important for the nurse to include which information in discussions with the client? Generally, a vast number of people recover from this condition. 278. The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply. Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose 279. The nurse notes that the client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse interprets that the client is most likely referring to infection of which structure that provides a protective covering for the eye? Conjunctiva 280. The client has undergone funduscopic examination of the eye. The documented results indicate that the blood vessels are without tortuosity, narrowing, pulsation, or nicking. The nurse interprets that this report indicates which finding? Normal retinal examination 281. The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation? The client has normal ocular movements. 282. The nurse assesses that a client with glaucoma has vision that is lost because of obstruction of aqueous humor flow by the trabecular meshwork. The nurse interprets that this client is suffering from which disorder? Primary open-angle glaucoma 283. The nurse is listening to a health care provider explain the results of an eye examination to a client. The health care provider states that the client has glaucoma resulting from a congenitally narrow anterior chamber angle, which has suddenly become blocked by the base of the iris. The nurse interprets that the health care provider is describing which type of glaucoma? Angle-closure glaucoma 284. A client is experiencing double vision, or diplopia. The nurse interprets that this client is experiencing a loss of which normal function of the eye? Binocular vision 285. After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom? Eye pain 286. A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube? Performing the Valsalva maneuver 287. The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull? Temporal 288. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. Monitor for hemorrhage. Administer eye medications. Maintain the eye patch or shield. Assist with activities of daily living. Educate regarding symptoms of retinal detachment. 289. A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply. Cerebral angiography Lumbar puncture (LP) Computed tomography 290. When the nurse taps at the level of the client's facial nerve, the following response is noted. How should the nurse document this finding on the client record? Refer to figure. Positive Chvostek's sign 291. The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response. How should the nurse document this response on the client's record? Refer to figure. Client demonstrated decerebrate posturing. 292. The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which clinical symptoms are observed? Hypotension and bradycardia 293. The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply. Tetany Diarrhea Possible seizure activity Positive Trousseau's sign 294. A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate? Withhold the dose and notify the registered nurse. 295. The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure. Facial 296. A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record? Refer to figure. Positive Kernig's sign 297. A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove which food items that arrived on the client's meal tray from the dietary department? Peas 298. The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action? Wrap a plastic bag filled with ice with a pillowcase and place it on the eye. 299. The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which position? Semi-Fowler's position 300. A client is about to undergo a lumbar puncture (LP). The nurse tells 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 301. The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client? Using many exaggerated hand gestures while talking 302. The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract? Difficulty with driving at night and blurred vision 303. The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction? "The hearing aid should not be worn if an ear infection is present." 304. The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location the nurse should do which action? Retract the upper eyelid and ask the client to look down. 305. A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information? The need for lifelong medication therapy 306. A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury? Bed rest with the head in semi-Fowler's position 307. A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first? Irrigate the eye with sterile saline. 308. A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care should encourage the client to limit or refrain from which usual activity on a repeated basis? Picking objects up off the floor 309. The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which bones connects to the cochlea at the oval window? Stapes 310. The nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse should diagram which structure as part of the inner ear? Cochlea 311. An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition? Nausea and vomiting 312. The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner? In a normal tone while facing the client 313. The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect? Acetaminophen (Tylenol) 314. A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position? Prone, with a pillow under the abdomen 315. A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerves (CNs)? CN VII 316. The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure? Decreasing pulse, decreasing respirations, increasing BP 317. A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which medication? Desmopressin (DDAVP) 318. A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client? Removing the weights when repositioning the client 319. The nurse is reinforcing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further teaching? "I will avoid driving at night because the vest limits the ability to turn the head." 320. A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? Allowing the client's bladder to become distended 321. The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment? Keeping the bed position raised to the nurse's waist level 322. The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Enlon). The nurse recalls that the client should have which reaction if the client has this disease? An increase in muscle strength within 1 to 3 minutes 323. A client with myasthenia gravis becomes increasingly weaker. The health care provider injects a dose of edrophonium (Enlon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis? A temporary worsening of the condition 324. Which symptoms would validate the diagnosis of a cluster headache? Select all that apply. A runny nose Burning sensation in the eye Tearing on the affected eye 325. A client, who frequently experiences hearing loss due to built-up cerumen in the ears, asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan? Select all that apply. Irrigate the ear canal with lukewarm tap water around 98° F. The ear irrigation should be stopped if the client becomes dizzy or nauseous. Instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation. 326. The nurse administers meclizine hydrochloride (Antivert) to a client diagnosed with an attack of Ménière's disease. Which observations demonstrate to the nurse that the medication is effective? Select all that apply. Decrease in nausea Decrease in vertigo 327. The nurse is reinforcing discharge instructions to a client who just underwent a myringotomy with placement of a polyethylene tube in the left ear. Which statement by the client indicates a need for further teaching? Select all that apply. "I may wash my hair tomorrow." "I will irrigate the ear with gentle pressure." "I can expect to feel pressure inside the ear." 328. The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure. Facial A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record? Refer to figure. Positive Babinski's sign The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures. -Jaw thrust maneuver 1. The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider? -Each rescue breath should be given over 1 second and should produce a visible chest rise. 2. The nurse attempts to relieve an airway obstruction on a 6-year-old conscious child. Which location is the correct placement of the hands to perform this maneuver? 3. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult. The nurse should deliver how many breaths per minute to the client? 4. The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, which is the compression rate for an infant? 5. Which is the most appropriate location for assessing the pulse of an infant who is less than 1 year old? 6. The nurse educator is teaching principles of cardiopulmonary resuscitation to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands the reason if the student makes which statement? 7. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. How far should the sternum be depressed in an adult client for effective chest compressions? 8. The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which? 9. The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 10. Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take? 11. An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity? 12. The nurse should plan which to encourage rebreak in the client who is a resident in a long-term care facility? 13. When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply. 14. The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance? 15. The nurse should implement which activity to promote reminiscence among older clients? 16. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 17. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to note documented in the health record when collecting data related to the respiratory system for this client? 18. The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding? 19. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note which finding? 20. The nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss? 21. While collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultates a murmur. Which best describes the sound of a heart murmur? 22. The nurse is preparing to assist the health care provider to test the extraocular movements in a client for muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done to assess for muscle weakness in the eye? 23. The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). The nurse explains that which is the best time to perform this exam? 24. The nurse notes that the physical assessment findings for a client with meningeal irritation indicate a positive Brudzinski sign. The nurse understands that which observation was made? 25. The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant which is the nurse's highest priority? 26. The nurse is preparing to perform an abdominal examination. The initial step should be which? 27. The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first? 28. To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm? 29. The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 30. Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system? 31. The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? 32. The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. 33. The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to figure. #3 34. The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client? 35. The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum should be depressed to least which depth? 36. An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Which statement indicates an understanding of the visual changes affecting the older client? 37. The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse tells the UAPs that which situation portrays ageism? 38. The nurse assigned to care for an older adult client places an extra blanket in the client's room. The nurse understands that the older adult is less able to regulate hot and cold body changes because of alterations in the activity of which gland? 39. The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client? 40. The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition? 41. The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which identifies the accurate procedure for this visual acuity test? 42. A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result? 43. The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test? 44. An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is least relevant to maintenance of balance for the older client? 45. In planning care for older clients in a long-term care facility, the nurse recalls that which is accurate regarding sexuality and the older client? 46. The nurse is working with an older client and family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that older persons usually prefer which? 47. An older client is taking multiple medications for a variety of health problems. The nurse should monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult? 48. The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse should incorporate which concept when formulating a response to the family member? 49. The nurse has gathered data regarding an older client. The nurse understands that which indicator of fluid imbalance is not reliable for a client in this age group? 50. The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6:00 pm. The nurse's response should be guided by which knowledge? 51. The nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment? #2 52. A client who has been seen in the clinic has been diagnosed with endometriosis and asks the nurse to describe this condition. The nurse bases the response on what information? 53. A nursing instructor asks a nursing student about the reason for the reduction of anesthetic medication dosage in the older person. Which statement is an appropriate response? 54. The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and the family? 55. A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which response by the husband as indicative of effective individual coping? 56. The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin? 57. A client and her husband are being discharged from the hospital after delivering a stillborn infant. They ask about the possibility of attending a bereavement support group in the community. Which response should this request indicate to the nurse? 58. Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly? 59. The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first? 60. The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority? 61. The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE? 62. A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. Which are probable signs indicating possible pregnancy? Select all that apply. 63. A client who was struck by a car while jogging is brought to the emergency department by the ambulance team. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancée is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which should the nurse implement? 64. The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure. #4 65. When collecting physical assessment data, the nurse understands that the spleen is located in which abdominal quadrant? Refer to figure. #2 66. When performing cardiopulmonary resuscitation (CPR), the nurse should deliver how many breaths per minute to an adult client? 67. The nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. Which is the proper compression-to-ventilation ratio for one-person CPR? 68. The nurse caring for the older adult client understands that dosages of many medications are reduced in this population because of which fact? 69. The nurse prepares to discharge a client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve the primary developmental task? 70. A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which should the nurse implement as the most effective measure to alleviate the spouse's distress? 71. A client's spouse becomes distraught when thinking about his wife's grave prognosis. Which action should the nurse implement to promote hope for the spouse? 72. To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas? 73. A licensed practical nurse (LPN) is providing instructions to an unlicensed assistive personnel (UAP) who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the UAP performs which action? 74. A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is discussing automated external defibrillation. A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which location on the client's chest? 75. The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? 76. The nurse should use which best method to open the victim's airway if the victim sustained a neck injury? 77. The nurse notes that an 8-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which landmarks to remove the foreign body? 78. The nurse employed in the pediatric unit working on the 11:00 ᴘᴍ to 7:00 ᴀᴍ shift finds an infant unresponsive and without respiration or a pulse. The nurse plans to deliver chest compressions at a rate of at least which? 79. The nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. After determining proper hand placement, the nurse begins delivering compressions by pushing down on the chest at which depth? 80. An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which? 81. An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which action next? 82. The nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, which action should the nurse perform? 83. The nurse is conducting a teaching session on basic life support (BLS) for nursing students. Which statement made by a nursing student indicates a need for further teaching? 84. The nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a nursing student to identify the structure in which fertilization of an ovum takes place. The student answers correctly by identifying which location? 85. The nurse is collecting data from a client who is suspected of having mittelschmerz. Which finding should the nurse expect to note on data collection of the client? 86. The nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which finding would most likely assist in verifying the suspicion? 87. The nurse is auscultating bowel sounds. Which are appropriate data collection methods? Select all that apply. 88. The nurse is caring for an 8-year-old child in the late stage of a terminal illness. The child is semiconscious. The nurse notices that the child has a dry mouth and the family believes the child is thirsty. The family is attempting to give the child a large glass of apple juice. Which actions should the nurse take? Select all that apply. 89. The nurse is caring for a client at the end of life. Which late cardiovascular and respiratory findings should the nurse expect to note while collecting data? Select all that apply. 90. The nurse is creating a care plan for a client with a terminal illness. Which nursing actions should be included? Select all that apply. -Respond to requests from the client and family promptly. -Support the client's decision-making in order to promote client control. -Provide information about what to expect during the dying process to the client and family. 91. The nurse is caring for a client at the end of life. Which gastrointestinal findings indicate that death is approaching? Select all that apply. 92. The nurse is caring for a client at the end of life. Which skin changes would the nurse expect to note? Select all that apply. 93. The nurse is caring for a client at the end-of-life. The client is withdrawn and agitated and is experiencing visual hallucinations. Which actions should the nurse take to provide end-of-life psychological care? Select all that apply. 94. The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply. The nurse is caring for a client who had a renal biopsy. Which interventions should the nurse include in the plan of care for the client after this procedure? Select all that apply. [Show More]

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