APEA PREDICTOR PRACTICE EXAM TEST BANK 2024-2025 VERSION WITH 500 COMPLETE QUESTIONS AND, Exams of Nursing

Download APEA PREDICTOR PRACTICE EXAM TEST BANK 2024-2025 VERSION WITH 500 COMPLETE QUESTIONS AND and more Exams Nursing in PDF only on Docsity! APEA PREDICTOR PRACTICE EXAM TEST BANK 2024-2025 VERSION WITH 500 COMPLETE QUESTIONS AND DETAILED CORRECT ANSWERS RATED A+ Which of the instructions should a nurse include in the teaching for a pt. who had removal of a cataract in the left eye? a. "Forcefully cough and take deep breaths every two hours to keep your airway clear." b. "Perform the prescribed eye exercises each day to strengthen your eye muscles." c. "Rinse your eyes with saline each morning to prevent postoperative infection." d. "Take the prescribed stool softener to avoid increasing intraocular pressure." d. "Take the prescribed stool softener to avoid increasing intraocular pressure." A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? a. Suction the nasogastric tube. b. Flush the tube with 30 mL of sterile water. c. Remove the nasogastric tube. d. Check the residual volume. d. Check the residual volume. Which of these actions best demonstrates cultural sensitivity by a nurse? a. The nurse talks in a slow-paced speech. b. The nurse asks clients about their beliefs and practices toward pregnancy. c. The nurse uses charts and diagrams when teaching pregnant clients. d. The nurse can speak several different languages. b. The nurse asks clients about their beliefs and practices toward pregnancy. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? a. Hyperreflexia. b. Tachycardia. c. Bradypnea. d. Agitation. b. Tachycardia. When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: a. the urinary meatus. b. vomitus. c. contaminated water. d. sexual intercourse. a. the urinary meatus. a. Vomiting and a pulse rate of 106/minute. Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication? a. The student maintains continuous eye contact with the client. b. The student places one arm around the client's shoulder? c. The student sits quietly next to the client. d. The student leaves the room to provide privacy for the client. c. The student sits quietly next to the client. Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia? a. Measure the client's blood sugar level. b. Administer a concentrated form glucose to the client. c. Administer a prn dose of insulin. d. Measure the client's urine for ketones. a. Measure the client's blood sugar level An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk? a. Increasing the time interval between medication doses. b. Limiting the client's oral fluid intake. c. Administering the medications with meals. d. Encouraging the client to void every three to four hours. a. Increasing the time interval between medication doses. A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? a. Explaining that staff does not poison clients. b. Focusing on how the hospital staff helps clients. c. Allowing the client to eat food from sealed containers. d. Telling the client that not eating the food that is served will result in privilege restrictions. c. Allowing the client to eat food from sealed containers. Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring? a. Gatch the knee of the bed. b. Administer anticoagulants preoperatively. c. Apply sequential compression devices. d. Maintain the legs in a dependent position. c. Apply sequential compression devices. When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: a. at least 15 pounds. b. 15 to 20 pounds. c. 25 to 35 pounds. d. at least 45 pounds. c. 25 to 35 pounds. Which of these manifestations, if reported by a client who is 10- weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy. a. Sharp unilateral abdominal pain. b. Uncontrollable vomiting. c. Marked abdominal distention. d. Profuse vaginal bleeding. a. Sharp unilateral abdominal pain. Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation? a. "Please bathe the client in room 12, and then bring the client to the dining room for breakfast by 9 A.M." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the pts. discomfort." c. "Please measure the intake and output for the client's in rooms 8. 9. and 10, and record each on the I&O sheets by 2 P.M." d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after lunch." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the pts. discomfort." A client has the following order for regular insulin (Humulin R) on a sliding scale: A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first? a. Assess the client. b. Notify the physician. c. Contact the nurse manager. d. Complete an incident report. a. Assess the client. An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take? a. Add a 5% dextrose solution to the line. b. Raise the head of the bed. c. Stop the transfusion. d. Measure the client's temperature. c. Stop the transfusion. When caring for a client who has hepatitis B, a nurse should wear: a. gloves when administering oral medications to the client. b. a gown when changing the client's position. c. gloves when removing the intravenous cannula. d. a gown when emptying the client's used bath water. c. gloves when removing the intravenous cannula. Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance? a. Absence of wheezing throughout the lung fields. b. Clear lung sounds on auscultation. c. Pulse oximetry level of 80%. d. Frequent coughing throughout the day b. Clear lung sounds on auscultation. A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child's mother to determine if the medication is being administered correctly? a. "Are you using a straw to administer the medicine?" b. "Has your child been urinating more frequently?" c. "Have you increased your child's milk intake each day?" d. "Is there a change in the color of your child's skin?" a. "Are you using a straw to administer the medicine?" Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated? a. Bulging anterior fontanel. b. Pulse rate of 120/minute. c. Decreased urine output. d. Cyanosis of the mucus membrane. c. Decreased urine output. Which of these instructions should be included in the teaching plan for the parents of a 10-month-old infant who is admitted to the hospital for failure to thrive? a. Advise the mother to make sure the infant drinks the entire bottle at each feeding. b. Encourage the mother to feed the infant slowly in a quiet environment. c. Teach the mother to position the infant on the abdomen following feedings. d. Instruct the mother to play actively with the infant during bottle feedings. b. Encourage the mother to feed the infant slowly in a quiet environment. When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize which of these conditions as a probable cause of the newborn's jaundice? a. Dehydration. b. Liver immaturity. c. ABO incompatibility. d. Gallbladder immaturity. b. Liver immaturity. Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet? a. Packet of a salt substitute. b. Grapefruit juice. c. Container of jelly. d. Ketchup. d. Ketchup. A nurse should recognize which of these signs is a probably sign of pregnancy? a. Frequency of urination. b. Positive pregnancy test. c. Nausea in the morning. d. Abdominal distention. b. Positive pregnancy test. All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? a. An 82-year-old client who bathes once a week. b. An 83-year-old client who applies powder after drying the skin. c. An 84-year-old client who has been NPO for four days. d. An 85-year-old client who has coronary artery disease. c. An 84-year-old client who has been NPO for four days. A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client has: a. had a period of sustained hyperglycemia. b. been non-compliant with home management. c. been in relatively good diabetic control. d. eaten a high carbohydrate snack just prior to testing. c. been in relatively good diabetic control. A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse include? a. Wearing disposable gloves when chaging the dressings. b. Having the client wear goggles when staff is in the room. c. Wearing a gown, mask, and gloves when providing care to the client. d. Disposing of the client's soiled laundry in a red bag. c. Wearing a gown, mask, and gloves when providing care to the client. A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5 mL. How many milliliters should a nurse administer? a. 1.0 b. 1.5. c. 2.0 d. 2.5 c. 2.0 A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? a. Include the 9:00 A.M. scenario in the shift report. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". c. Put the information in the margin and indicate the accurate time placement by drawing an arrow. d. Draw a line through the previous charting with "error" and then re- record everything, including the new information. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these interpretations and additional assessments should the nurse make? a. The client's skin is sensitive to touch; lightly rub the client's chest area. b. The client has decreased circulation; palpate the peripheral pulses. c. The client is showing signs of pressure; press on the skin and observe for a return of color. d. The client is allergic to the soap; check the extremities for discoloration. c. The client is showing signs of pressure; press on the skin and observe for a return of color. A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn's treatment, a nurse should: a. cover the newborn's closed eyes with patches. b. measure the newborn's pulse and respirations every two hours. c. keep the newborn under the light at all times, even during the feedings. d. notify the physician if the newborns stools become greenish yellow. a. cover the newborn's closed eyes with patches. a. "Take a deep breath, then cough and spit into this container." b. "Gargle with antiseptic mouthwash before you spit into this container. c. "Spit whatever sputum you have in your mouth into this container." d. "Drink some fluids to loosen your secretions and the spit into this container." a. "Take a deep breath, then cough and spit into this container." A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than body requirements related to diminished taste perception and nausea. Which of these additional nursing diagnoses should a nurse consider for the client? a. Risk for aspiration. b. Ineffective protection. c. Risk for deficient fluid volume. d. Altered tissue perfusion. c. Risk for deficient fluid volume. Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse that the parent understands the teaching about a gluten-free diet? a. Broiled steak, baked potato, and spinach. b. Pork chop, egg noodles, and green peas. c. Fried chicken, white roll, and mixed vegetables. d. Baked macaroni with cheddar cheese and corn. a. Broiled steak, baked potato, and spinach. Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client's feelings and concerns? a. "You appear anxious and tense." b. "Everything will be okay." c. "I notice you're biting your nails." d. "I'm not sure I understand what you're saying." b. "Everything will be okay." A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the wrong thing and not get the job." Which of these responses, if made by the nurse, will create a communication barrier? a. "Would you like to practice the interview?" b. "Have you thought about some possible questions that may be asked in the interview?" c. "Tell me more about your concerns." d. "You need to relax, and everything will be fine." d. "You need to relax, and everything will be fine." A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and lightheadedness. Which of these assessments should a nurse make? a. Determine the client's preferred diet. b. Measure the client's body temperature. c. Auscultate the lungs. d. Ascertain the client's typical sleep pattern. b. Measure the client's body temperature. Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg injury? a. Ensuring adequate hydration for the child. b. Soaking the child's injured leg in warm water. c. Administering the missing factor VIII to the child. d. Transfusing one unit of whole blood to the child. c. Administering the missing factor VIII to the child. Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago? a. Preventing hemorrhage. b. Preventing pneumonia. c. Preventing aspiration. d. Preventing dehydration. c. Preventing aspiration. A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and reports shortness of breath and dizziness. Which of these interpretations and actions should a nurse take? a. This is an expected occurrence following bypass surgery; continue to monitor the client. b. This indicates normalization of the blood pressure; hold all anti- hypertensive medications. c. This may be an early sign of heart failure; notify the physician. d. This indicates hypoxia; administer oxygen at 5/L per minute. c. Troponin level. d. Hemoglobin. c. Troponin level. A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout the pregnancy to measure: a. specific gravity and pregnancy hormones. b. culture and white blood cell count. c. glucose and protein. d. bacteria and red blood cell count. c. glucose and protein. Which of these manifestations should a nurse expect to observe in a client who is diagnosed with paranoid schizophrenia? a. Regression. b. Suspiciousness. c. Catatonia. d. Hyperactivity b. Suspiciousness. Which of these measures should an emergency room nurse include when speaking with a family experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? a. Explaining to the parents how SIDS could have been predicted. b. Discouraging the parents from viewing the infant's body. c. Encouraging the parents to take the opportunity to say goodbye. d. Interviewing the parents in-depth about the circumstances of the infants death. a. Explaining to the parents how SIDS could have been predicted. Which of these assessments is the priority for a client who is admitted with recurrent depression? a. Previous episodes of depression. b. Compliance with prescribed medications. c. Presence of a suicide plan. d. Problems with communication. c. Presence of a suicide plan. Which of these changes in the assessment data of a child who has congestive heart failure should a nurse recognize as indicative of a therapeutic response to prescribed medication therapy? a. Increased weight. b. Increased urine output. c. Increased respiratory rate. d. Increased heart size. b. Increased urine output. Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate? a. The UAP is assigned to measure a client's intake and output. b. The UAP is assigned to assess a client's lung sounds. c. The UAP is assigned to teach a client about diet restrictions. d. The UAP is assigned to change a client's postoperative wound dressing. a. The UAP is assigned to measure a client's intake and output. A client who has a history of asthma develops an acute asthma attack. Which of these questions should a nurse ask when assessing the etiology of this attack? a. "Have you eaten any new foods recently?" b. "How many hours did you sleep last night?" c. "Are you exercising every day?" d. "Have you reduced your fluid intake recently?" a. "Have you eaten any new foods recently?" Which of these foods should a nurse suggest that a client who is diagnosed with iron-deficiency anemia choose for dinner? a. Cooked dry beans, green leafy vegetables, and dried fruits. b. Raw cabbage, tomato juice, and cantaloupe. c. Fresh fish, peanut butter, and oatmeal. d. Cheddar cheese, enriched bread, and yellow vegetables. a. Cooked dry beans, green leafy vegetables, and dried fruits. A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-pregnant primarily to: a. turn the fetus in the uterus. b. ease the fetus into the true pelvis. c. assessment of the location of the placenta. d. determine the fetal presentation A nurse plans to assess a client's recent memory. Which of these questions should the nurse include? a. "Who is your closest friend?" b. "What was the name of the school you attended?" c. "What day were you admitted to the unit?" d. "What did you have for breakfast?" d. "What did you have for breakfast?" A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick now?" Which of these responses, if made by the nurse, is therapeutic? a. "You will need to find someone to talk over your fears on a regular basis." b. "What do you think is making you feel so anxious now?" c. "Are you aware that there are newer, more effective treatments for breast cancer?" d. "Tell me more about your concerns." d. "Tell me more about your concerns." Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair, is correct? a. The bed is raised to a comfortable working height for the nurse. b. The wheelchair is placed perpendicular to the bed. c. The nurse stands behind the client during the transfer. d. The nurse supports the client in an upright standing position for a few moments. d. The nurse supports the client in an upright standing position for a few moments. A nurse should assist a pregnant client who is in the first trimester to achieve the developmental task of this stage of pregnancy, which is: a. accepting the fact that she is pregnant. b. accepting the fact that the fetus is a separate being. c. accepting that she will soon deliver the child. d. accepting that her body image has changed. a. accepting the fact that she is pregnant. When interacting with a client who is paranoid, a nurse should: a. use touch to place the client at ease. b. maintain a caring facial expression. c. stand close to the client. d. maintain a professional attitude towards the client. d. maintain a professional attitude towards the client. Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care unit? a. Feeding a client who was admitted with a stroke yesterday. b. Ambulating a client who was admitted with a myocardial infarction yesterday. c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday. d. Suctioning the tracheostomy that was performed on a client yesterday c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday. Which of these techniques should a nurse plan to use with a client who is delusional? a. Explore the delusion so the client will know it is false. b. Explain clearly why the client's belief is incorrect. c. Focus on reality-based topics. d. Avoid speaking with the client when he/she is delusional. c. Focus on reality-based topics. Which of the following manifestations should a nurse recognize as suggestive of right-sided heart failure? a. Cool extremities and frothy sputum. b. Jugular vein distention and pedal edema. c. Orthopnea and frequent cough at night. d. Weight loss and lower calf pains. b. Jugular vein distention and pedal edema. Which of these statements, if made by a nursing student prior to a sterile dressing change, is correct? a. "I understand that if objects touch other objects on the sterile field they are considered contaminated." b. "I understand that sterile objects that are below my waist are considered contaminated." c. "I understand that all objects in the sterile field must be dry." c. How much alcohol does this student drink? d. Is this student feeling anxious? a. Is this student an athlete? Which of the following clients should a nurse recognize is most likely to develop diabetic ketoacidosis? a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess. b. A 31-year-old gestational diabetic who has occasional bout of nausea. c. A 55-year-old who has type 2 diabetes mellitus and is adjusting well to the lifestyle changes. d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise. d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise. Which of these postoperative complications in the first hour after surgery requires immediate intervention? a. Serous draining on the dressing. b. Swelling of an extremity under a cast. c. Vomiting. d. Dehiscence of a wound. d. Dehiscence of a wound. Which of these assessments should a nurse make of a client who had a knee replacement this morning? a. Pain. b. Signs of infection. c. Bowel movement frequency. d. Range of motion. a. Pain. Which of these actions should a nurse take prior to assisting an elderly client to shave his face? a. Have the client sign a consent form. b. Determine what medications the client takes. c. Soften the client's skin by applying lotion. d. Cleanse the face with a bactericidal solution. b. Determine what medications the client takes. Which of these factors should a nurse consider when delegating tasks to unlicensed assistive personnel (UAP)? a. The UAP's relationship with clients. b. The UAP's willingness to perform tasks. c. The UAP's previous experiences on the unit. d. The UAP's duration of employment on the unit. c. The UAP's previous experiences on the unit. Which of these nursing diagnoses is the priority for a young adult client who has first-degree burns of the legs and smoke inhalation from a fire in the home? a. Pain. b. Risk for infection. c. Impaired gas exchange. d. Body image disturbance. c. Impaired gas exchange. A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks. To determine if the desired effects of the Pancrease are achieved, a nurse should consider which of these questions? a. Is the child's blood sugar level within normal limits? b. Has the child's appetite improved with the medications? c. Are the child's stools of normal consistency? d. Does the child report increased belching and flatus? c. Are the child's stools of normal consistency? When assessing a group of children, a nurse should recognize which child is at increased risk of developing acute glomerulonephritis? a. A 3-year-old who has multiple urinary tract anomalies. b. A 4-year-old who had a streptococcal infection a week ago. c. A 5-year-old who has recurrent enuresis at night. d. A 6-year-old who had chicken pox infection two weeks ago. b. A 4-year-old who had a streptococcal infection a week ago. A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom. I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they do." Which of these problems should the nurse focus on first? A nurse is preparing a client for a vaginal examination. Which of these statements should the nurse make? a. "Go into the bathroom and empty your bladder." b. "Cleanse your perineal area with betadine solution." c. "Hold your breath while the speculum remains in place." d. "Push down as the doctor inserts the speculum." a. "Go into the bathroom and empty your bladder." A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A 25-year-old client who is terminally ill with metastatic testicular cancer. b. A 37-year-old client who has second-degree burns on both feet. c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion. d. A 68-year-old client who is bed bound related to severe Parkinson's disease. c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion. Which of these preventative measures should a nurse manager in a long-term care facility plan to institute to decrease clients' risks for falls? a. Monitoring clients frequently for evidence of activity intolerance. b. Placing all client personal items in the bedside drawers. c. Raising the side rails for all clients who have memory impairment. d. Maintaining all client beds in the highest position. a. Monitoring clients frequently for evidence of activity intolerance. Which of these assessment findings, if present in a primigravida, indicates that the client is experiencing true labor? a. The pains are felt in the lower abdomen, back, and groin. b. The Braxton-Hicks contractions have become stronger and more frequent. c. There is an increased amount of white mucus discharge. d. There is a progressive increase in effacement and cervical dilatation. d. There is a progressive increase in effacement and cervical dilatation. A client is admitted for opiate detoxification for the fifth time. Which of these statements, if made by a staff member, indicates a biased view of the client? a. "I feel so frustrated when clients are re-admitted." b. "Addicts relapse because they don't try hard enough." c. "I think this client needs to consider long-term placement after detoxification." d. "The team really needs to discuss this client's treatment plan." b. "Addicts relapse because they don't try hard enough." Which of these women, each of whom is in labor, should a nurse recognize as in need of immediate attention? a. A woman who is having contractions every 6 to 8 minutes of mild to moderate intensity. b. A woman who is receiving oxytocin augmentation and who has contractions lasting 60 to 70 seconds. c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement. d. A woman whose uterine contractions frequency is every two to give minutes. c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement. A nurse has received a report on these assigned clients. Which client should the nurse follow-up first? a. A client, admitted with acute diverticulitis, who has a white blood cell count (WBC) of 10,000 mm3. b. A client, admitted with acute pancreatitis, who has a fasting serum glucose of 130 mg/dL today, and had a reading of 160 mg/dL yesterday. c. A client, admitted with hepatitis, who has jaundice and tea-colored urine. d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today. d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today. Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize as indicative of the need for additional instructions? a. "I take all of my medications at bedtime so I don't forget them." asthmaticus. c. Ambulating a client who had a hip replacement three days ago. d. Changing the dressing for a client who had wound debridement last week. c. Ambulating a client who had a hip replacement three days ago. A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse should prepare the woman to have an immediate sonogram to determine the: a. location of the placenta. b. uterine response to labor. c. the fetus's current weight. d. condition of the uterine vascular bed. a. location of the placenta. A nurse is planning to interview a client who speaks limited English. Which of these strategies should the nurse include? a. Smile frequently during the interview interview to reduce the client's anxiety. b. Observe the client for indicators of confusion or not understanding questions. c. Maintain constant eye contact throughout the interview. d. Keep the interview short to decrease the client's fatigue. b. Observe the client for indicators of confusion or not understanding questions. A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a well-child visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the child to weight at this visit? a. 14 lbs, 2 oz. b. 18 lbs, 6 oz. c. 28 lbs, 8 oz. d. 45 lbs, 10 oz. c. 28 lbs, 8 oz. A nurse has been discussing the nutritional needs of children with a group of parents in a clinic. Which of these statements, if made by the parent of a 2-year-old child, should the nurse follow up? a. "I give my child slices of cheese as an afternoon snack." b. "I give my child a cup of skim milk as an afternoon snack." c. "I give my child some popcorn as an afternoon snack." d. "I give my child some yogurt as an afternoon snack." c. "I give my child some popcorn as an afternoon snack." Which of these client care situations has the greatest potential for presenting an ethical dilemma for a nurse? a. Participating in pregnancy termination procedures. b. Counseling a client who is terminally ill with AIDS. c. Discussing contraception options with adolescents. d. Caring for a client who is from a different culture than the nurse. a. Participating in pregnancy termination procedures. Which assessment information should a nurse obtain first when a pregnant woman and her husband arrive at the Labor and Delivery Unit? a. Whether the couple attended birthing classes. b. The frequency and intensity of labor contractions. c. The number of previous pregnancies and outcomes. d. The amount and time of the client's last food intake. b. The frequency and intensity of labor contractions. A client who has Parkinson's disease has been identified as being at risk for falls. Which of these actions by a nurse is most likely to reduce the client's risk of falling a. Monitor the client's blood pressure after ambulation. b. Ensure the client wears socks when ambulating. c. Encourage frequent weight-bearing exercise. d. Assign an assistant to remain with the client when ambulating. d. Assign an assistant to remain with the client when ambulating. A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client who has preeclampsia is achieved when there is increased: a. urinary output. b. blood pressure. c. respiratory rate. d. uterine movement. a. urinary output. Which of these assessments is the initial priority of a client who is one-hour postoperative after an exploratory laparotomy? c. Raising muffin. d. Green salad. b. Bran flakes. Which of these discharge instructions should a nurse include for a client who has a ruptured tympanic membrane that occurred during a fall? a. "No showers or washing of the hair for the next month." b. "Avoid yawning or holding your head down." c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization." d. "Avoid swallowing and coughing until your ear has healed." c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization." Which of these nursing measures is appropriate for a client who has recurrent renal calculi? a. Weighing the client daily before breakfast. b. Measuring the blood pressure every four hours. c. Encouraging a daily intake of three liters of fluids. d. Testing the urine for protein each shift c. Encouraging a daily intake of three liters of fluids. When auscultating the lungs of a woman who is admitted for severe pregnancy-induced hypertension, a nurse notes the presence of crackles and moist respirations. These assessment findings most likely indicate which of these complications? a. A convulsion is imminent. b. Pulmonary edema has developed. c. Bilateral lobar pneumonia is present. d. Respiratory failure is evident. b. Pulmonary edema has developed. A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A client who is eight-hours postoperative after a hip replacement. b. A client who is drowsy after falling out a third story window. c. A client who is four hours post-colonoscopy and polyp removal. d. A client who is dysphasic after a transient ischemic attack. b. A client who is drowsy after falling out a third story window. Which of these clients is at the highest risk of developing osteoporosis? a. An obese African American adolescent who does not exercise. b. A pregnant Asian client who is a vegetarian. c. A middle-aged Native-American male who is quadriplegic. d. A thin, elderly Caucasian female who lives alone. d. A thin, elderly Caucasian female who lives alone. A nurse is obtaining the health history of a client who is admitted for surgical repair of an inguinal hernia. Which of these factors should the nurse recognize as having the greatest impact on the outcome of the surgery? a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain. b. The client drinks one glass of beer every evening with dinner. c. The client had a knee replacement six months prior to this admission. d. The client is allergic to all penicillin-type antibiotics. a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain. A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD), needs additional instructions if the client makes which of these statements? a. "I will try to take slow, deep breaths when I feel short of breath." b. "I will use the albuterol (Proventil) nebulizer before I eat. c. "I will drink most of my fluids between meals." d. "I will turn up the oxygen flow rate if I have difficulty breathing." d. "I will turn up the oxygen flow rate if I have difficulty breathing." A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her spouse. Which of these statements, if made by a nurse, is therapeutic? a. "You should leave this relationship now or you will be sorry." b. "Are you aware that women who remain in abusive relationships eventually are killed?" c. "This type of abuse typically recurs after a period of remorse by the abuser." d. "Can you think of what you did to cause this abuse?" Contact security personnel to place the money in the facility safe. 13.A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration? Subcutaneously. 14. A nurse is reinforcing teaching about car seat safety to the parents of a newborn, The nurse should instruct the parents to place the car seat in a? Rear-facing position in the back seat. 15. A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in which of the following situations? A hospital risk manager includes information from a client's medical record in 16.A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take? Notify the charge nurse of the finding. 17. A nurse is caring for a full-term newborn who was circumcised 6 hours ago, which of the following findings indicates that the newborn is experiencing pain? Furrowed Brow 18. A nurse is reinforcing teaching with a client about organ donation. Which of the following client statements indicated a need for further teaching? "My doctor should decide if my organs will be donated." 19. A Client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take this medication because it makes me tired all the time." Which of the following is the appropriate response? "Let's talk with your doctor about other options." 20. A nurse is preparing to administer an IM injection to a client. To reduce the risk of needle stick injury, the nurse should? Dispose of the used needle immediately in a puncture-proof sharps container. 21.A Nurse is contributing to the discharge plan for a client following surgery. Which of the following findings indicate the need for an interdisciplinary care conference? The client requires assistance to pay for dressing supplies. 22.A client who is 24 hour postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and cough. Which of the following actions should the nurse take first? Elevate the head of the client's bed. 23.A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent? Obtain verbal consent from the client while waiting for the parents to arrive. b. Witness the signature of the client's parent when he arrives. c. Have the client's older sibling give consent if a parent is not available. d. Delay the procedure if the provider cannot contact the parents. 24. A nurse has delegated care to an assistive personnel. At the end of the shift, the Ap asks the nurse to enter data for her because the AP has forgotten her password and needs to leave, Which of the following actions should the nurse take? Tell the AP to contact the IT department for charting assistance 25. A nurse is reinforcing discharge teaching to a client following a gastrectomy, to prevent dumping syndrome, which of the following foods should the nurse instruct the client to avoid? Ice Cream 26. A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas testing, which of the following client statements indicated an understanding of the purpose of drawing arterial blood gases? "This will indicate how much acid is building up in my blood." 27. A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of the following client care situations should the nurse manager intervene? Nurse discards a bottle of sterile saline after it has been open for 24 hours 28. A nurse is collecting data from a client who reports recent weight loss and a Chronic cough that is now producing blood-streaked sputum. For which of the following should the nurse expect the client to have diagnostic testing? A. Lung Cancer B. Emphysema. 29.A nurse is caring for an older adult client with a decreased level of consciousness. Which of the following is an appropriate intervention related to the client's mouth care? Uses a sponge toothette to cleanse the inside of the mouth. 30.A nurse in a long-term care facility nuts that the assistive personnel lack knowledge of blood glucose monitoring, The nurse 43. A client's daughter calls the nurse requesting information about her mother's condition, the client's chart does not specify that information can be released to the daughter, which of the following is an appropriate response by the nurse? "You will need to contact your mother directly about her condition." 44. A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam, which of the following should indicate to the nurse the child is not current with the minimum required immunization? One MMR vaccine. 45.A nurse is reinforcing teaching with a new mother on facility security measure, which of the following statements by the mother indicates that the teaching was effective? "I will have an identification band that matches the one my baby wears." 46. A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she? Develops edema of the ankles. 47.A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate? Monitor the client's skin integrity on a regular schedule. 48. A nurse is working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate? Aggressive behavior 49. A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first? A client who has COPD and dementia and was agitated during the night shift. 50. A nurse is applying a condom catheter to a male client who is incontinent which of the following is an appropriate technique to use? Leave space between the tip of the penis and the end of the condom catheter. 51. A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take? Ask the client to flex the hips and knees. 52.A nurse is supervising an assistive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take? Reinforce safe meal setup techniques. 53. A nurse is reinforcing teaching to a first-time mother about toddler safety, the nurse should recognize the client's understanding of the teaching when the client states, "I will? Install gates at the top and bottom of the stairs." 54. A nurse is preparing a sterile field to perform a dressing change, which of the following actions should the nurse take? Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field. 55. A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states. "I guess I have to take some of the blame because of the way my friends and I dress." 56. A client is prescribed 2g of ampicillin, The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client? 4 tablets. 57. A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching? "I will walk barefoot to prevent slipping." d. "I will check my smoke alarms once a month." 58. A Client with emphysema asks the nurse why he has difficulty exhaling, Which of the following statements by the nurse is appropriate? "Your windpipe is inflamed and constricted." 59.A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal, which of the following is an expected finding for the client? Irritability. 60. A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparation classes. Which of the following responses by the nurse supports the partner's involvement during labor? "Breathing with your partner will help her to relax during contractions." 61. A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first? Remove the tracheostomy inner cannula. 74.A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using? Rationalization. 75.A nurse is reinforcing teaching with a new mother of a full-term newborn about breastfeeding. The newborn is 5 days old. Which of the following statements by the mother indicates an understanding of the teaching? I should have my baby latch on to my nipple and areola during feeding." 76.A nurse is reinforcing teaching to the parent of a child who has been prescribed ferrous sulfate (Feosol) in liquid form. Which of the following statements made by the parent indicates the teaching was effective? "I will give the iron through a straw." 77.A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? 150 mL/hr 78.A nurse is reinforcing teaching to a group of adolescent males. Which of the following statements made by a student indicates a need for further teaching? "I should perform a self-exam of my testes once a year." 79.An infant is admitted to a pediatric unit following a motor-vehicle crash with a subsequent head injury. For which of the following should the nurse monitor to identify increased intracranial pressure? Decreased motor response. 80.A nurse is caring for a client who is terminally ill and requires ongoing palliative care. Which of the following interventions is consistent with the goals of this type of care? Allowing the family overnight visitation. 81.A nurse in an inpatient psychiatric unit is a caring for a client who was raised in an Asian culture. Which of the following communication techniques demonstrates cultural sensitivity? Holding eye contact for brief instances. 82.A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following actions should the nurse take? Instruct the client to take slow, deep breaths. 83.A newly admitted client tells the nurse that he does not have an advance directive. Which of the following is the appropriate action for the nurse to take? Provide the client with written information about advance directives. 84.A nurse is observing a client who is in the manic phase of bipolar disorder. The client states, "Don't need to eat today. Where's the money? Time to write that speech." The nurse should document this as which of the following? Flight of ideas. 85. A nurse is reinforcing dietary teaching to a client who has end- stage renal failure. Which of the following instructions should the nurse include in the teaching? a. Decrease calcium intake. c. Decease sodium intake. 86. A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client's belongings, which of the following items should the nurse remove from the client's suitcase? b. Perfume d. Emery Boards. 87. A nurse is collecting data from a client at an urgent care clinic. The client tells the nurse that she hasn't been able to sleep since the death of her father 2 days ago. Which of the following is the nurse's priority action? Discuss coping skills that have worked for the client previously. 88. A nurse is planning care for a client who is 6 hours postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's care plan? Place a pillow under the client's surgical knee. 89. A nurse in pediatric clinic is reviewing the history of a 11-year-old child. Which of the following immunizations should the nurse anticipate administering? Rotavirus c. meningococcal conjugate 90. A nurse is caring for a client who was recently diagnosed with paranoid schizophrenia and is taking risperidone (risperdal). Which of the following statements by the family indicates a need for further teaching? Our son's symptoms will stop as soon as he begins his medications. 91 A nurse is caring for a newly postoperative client who has unilateral breath sounds and asymmetrical chest expansion. The nurse should recognize these findings are indicative of which of the following and should be reported to the provider? Atelectasis. 104. A nurse is preparing to apply a pulse oximeter to a client's finger. Which of the following actions should the nurse take before applying the sensor? Check the client's capillary refill. 105. A nurse is caring for a client who is asking about the technique of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique? "It is a light stroking of the skin during a uterine contraction." 106. A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoprerative pain. Which of the following is an adverse effect of this medication? Urinary Retention. 107. A nurse is administering medication. A client states, "I know that the Inderal helps my blood pressure, but I don't like the way it makes me feel, I don't think I'll take it today." Which of the following actions should the nurse take? Ask the client to describe what he is experiencing. 108. A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate? "Think about a pleasant memory as you visualize your pain floating away." 109. A nurse is caring for an older adult client who is postoperative following a total hip replacement. The client is incontinent of stool and urine. To prevent skin breakdown, the nurse should? Apply moisture-absorbing undergarments. 110. A client comes to the clinic with reports to nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe? Pseudoephedrine (Sudafed) 111. A nurse is provider's office is reinforcing teaching to the parents of a school- age child who has an ankle sprain. The nurse should include which of the following statements in the teaching? "Offer aspirin every 4 hours for discomfort." c. "elevate the affected extremity to a level higher than the heart." 112. A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for further data collection? A. Inappropriate words when speaking. Sharp sensation when touched with safety pin point. 113. A nurse is reinforcing teaching with the parents of a 1-year-old infant regarding appropriate play activities for this age group. Which of the following activities should the nurse include? This is an appropriate toy for a 12-month-old infant. Beads that are too large to pass through a toilet paper tube do not present a choking hazard. This toy would provide visual and tactile stimulation for a 1-year-old infant 114. A nurse is reinforcing teaching to the parents of an infant who has pavlik harness. Which of the following statements should the nurse include in the teaching? "The harness promotes hip joint development." 115. A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention? States he is being told to hit his roommate. 116. A nurse is reinforcing teaching for a client who has just started taking amitriptyline (Elavil). Which of the following should the nurse include as an adverse effect of this medication? Orthostatic hypotension. 117. A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first? Check for proper fit of the mask on the CPAP machine. D. Provide activities during the day to stimulate the client. 118. A nurse is caring for a client in the provider's office who has is experiencing an episode of acute asthma. The nurse should administer which of the following medications? Traimcinolone (Azmacort) 119. A nurse is assisting with the care of a client who is receiving IV therapy of 0.9% sodium chloride. The client received 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because? The client was not harmed as a result of the incident. 120. A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching? I will rinse my mouth with room-temperature saline solution. 135. A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching? d. "I will leave the patch on for 12 to 14 hours each day." 136. A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error? a. Incident report 137. A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement? d. Take the client for a walk to the recreation room. 138. A nurse is reinforcing teaching about levothyroxine (synthroid) to a client has hypothyroidism. Which of the following should the nurse instruct the client to expect? b. Increased energy c. weight loss. 139, A nurse is caring for a client who is in bed and experiencing a toni-clonic seizure. Which of the following actions should the nurse take? Place the bed in the lowest position. 140. A nurse is preparing to irrigate a wound of a client who has methicillin- resistant Staphylococcus aureus (MRSA).The nurse should use which of the following personal protective equipment? A face shield 141. A nurse is collecting data for a client who has been receiving medroxyprogesterone acetate (Depo- Provera) for the past 6 months. Which of the following statements made by the client should be reported to the provider? "I'm experiencing calf pain." 142. A nurse is reinforcing teaching with a new mother regarding the use of breast milk. Which of the following statements by the mother indicates an understanding of the teaching? I can store my breast milk in the freezer for up to 6 months. 143. A nurse in a long-term care facility is caring for a client who has spinal cord injury. The client is demonstrating manifestations of autonomic dysreflexia. Which of the following actions should the nurse take first? Check the client for bladder distention d. Loosen the client's clothing. 144. A nurse is caring for a toddler who was admitted for pneumonia. Which of the following findings has the highest priority? Respiratory rate of 36/min 145. A nurse is reinforcing teaching for a client regarding various forms of contraception. The nurse should recognize that the client understands the instructions if she says, "I will? Use a spermicide with condoms to increase the effectiveness." 146. A nurse is preparing to administer K+ gluconate (kaon) 60mEq PO in three equally divided doses. Available is K+ gluconate 20 mEq/15 mL. How many mL should the nurse administer with each dose? 15mL 147. A nurse is reinforcing teaching to a client who has GERD and is prescribed raintidine (Zantac). Which of the following indicates an understanding of the teaching? I have to remain upright for 1 hours after taking the medication. 148, A nurse is reinforcing teaching with a client diagnosed with diabetes mellitus requiring insulin injections. Which of the following statements made by the client indicates understanding of the teaching? I should remove bubbles from the syringe before injecting my insulin. 149. A client newly diagnosed with bipolar disorder asks the nurse, "How long will I have to take lithium?" Which of the following is an appropriate response by the nurse? Medication is usually continued for 6 months after symptoms subside. 150 A nurse in the birthing unit is assisting with the care of a client who is at 38 weeks gestation and has bring red vaginal bleeding but denies pain? Placenta previa. 151. A nurse is reinforcing teaching regarding the dietary intake needed to reduce the risk of neural tube defects with a client who is planning to become pregnant. Cooked spinach 152, The parent of a 3-year-old child tells the nurse that he is concerned because his daughter has begun playing with an imaginary friend. Which of the following is an appropriate response by the nurse? This is a common behavior for children of this age. 165. A nurse is caring for a client who was placed in a cast 12 hr ago due to a fractured left tibia. Which of the following findings is the highest priority? Numbness in the left foot. 166. A nurse is collecting data from a female client who wishes to begin oral contraception. Which of the following is a contraindication to the use of oral contraceptives? Current use of nicotine. 167. A nurse is monitoring a client who is receiving a unit of packed red blood cells (PRBCs). The nurse recognizes an allergic reaction when the client reports. urticaria. 169. A nurse finds a client's wife crying in the hallway. she states, "I just don't know how I am going to go on after he is gone." Which of the following is an appropriate response by the nurse? Tell me more about how are you feeling. 170. A nurse is caring for a client whose previous blood pressure reading have been within the expected reference range. The client's current blood pressure reading is suddenly elevated above the expected range. Which of the following factors can contribute to a false high blood pressure reading? The blood pressure cuff is too small for the client's arm. 171. A nurse is caring for a client who is experiencing respiratory acidosis. The nurse should expect which of the following serum pH levels? pH 7.30 172. A woman who is postmenopausal presents to a clinic for a well- woman examination. She tells the nurse that she does not understand the need for a Pap test because she is no longer experiencing menses. Which of the following responses by the nurse is appropriate? A pap test can help with early detection of cervical cancer. 173. A nurse in provider's office is talking on the phone with a parent of a school- age child who has varicella. The parent asks the nurse when the child can return to school. The nurse tells the parent the child is no longer contagious when All vesicles have crusted over. 174. A nurse is collecting data from a client who is in her third trimester of pregnancy during a routine prenatal visit to the provider's office. The client reports she feels dizzy, has clammy skin, and becomes pale while lying down. The nurse should tell the client that when she feels this way, she should do which of the following? Lie on her left side. 175. A nurse should monitor a client who is taking Lasix for which of the following adverse effects? Hypokalemia. 176. A nurse is implementing a bladder training program for a client after a cerebrovascular accident. Which of the following interventions by the nurse is appropriate for the client? Check for residual urine after voiding. 177. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? Dependent edema 178. A nurse is reinforcing teaching to an adult client who is prescribe Lipitor. The nurse should advise the client that which of the following is an adverse effect of this medication and should be reported to the provider? Unexplained muscle pain 179. A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel? Ambulating a client receiving patient-controlled analgesia. 180. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis. Which of the following findings should the nurse expect? Nuchal rigidity A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? Document the client's condition every 15 minutes A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? Administer analgesics on a scheduled basis for the first 24 hr A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A client who has a hip fracture and a new onset of tachypnea A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? Wear gloves to apply the patch to the client's skin isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? The client is showing evidence of phenytoin toxicity A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? Increase in frequency of swallowing (may indicate bleeding) A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? Monitor the child's cardiac status A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? Use of tobacco decreases the level of athletic ability A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? Serum potassium- diuretic that retains potassium= hyperkalemic risk A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? "I will let the client know that I am available as the interpreter." A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? A two day old newborn who has a respiratory rate of 70 (30 - 60 is normal) A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia A client who has fractured left tibia and pallor in the affected extremity A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? Potato pancakes A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? Disorganized speech A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? Apply an orthotic to the clients foot A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? Provide anticipatory guidance classes to parents through public schools A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? Below the knee amputation A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? Platelets 100,000/mm3 (150,000-300,00 risk for bleeding) A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? Prealbumin 10 mcg/dl (normal: 16-40) A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the - Let's talk about your mom's cancer and how things will progress from here. - Tell me how you are feeling about your mom dying. - You sound like you have questions about your mom dying. Let's talk about it. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? A client who received a Mantoux test 48 hours ago and has induration A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? Clarify the source of the referral A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? You have the right to decide who receives information A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 90.7 (200 lb). The nurse should identify the weight of the following total percentage? 7.5% A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? Pour water from a squeeze bottle over the client's perineal area. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? Avoid hot tub while wearing the patch A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? We should establish our roles in the initial session. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) 1. Transport the client to another area of the nursing unit 2. Activate the facility's fire alarm system 3. Close all nearby windows and doors 4. Use the unit's fire extinguisher to attempt to put out the fire A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? Whole grain bread A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? Heightened perceptual field A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (SATA) Tremors Diaphoresis Inability to concentrate A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? Weak femoral pulses A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? Primary - before it happens Secondary - screening Tertiary - already happened Teach parenting skills to families at risk for abuse A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? Applying a condom catheter for a client who has a spinal cord injury notifying the provider, which of the following actions is appropriate for the nurse to take? Explain the risks of leaving A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? "I think the baby should be sleeping through the night by now. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? Sunken fontanels and dry mucous membranes A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? Vitamin b12 level A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? Perform post mortem care A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored? Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ? Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ? Excessive sweating A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? This test should be performed after you baby is 24 hours old A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? Perform the procedure twice a day A nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? Administering potassium via IV bolus A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? Use an albuterol inhaler A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? Monitor the dorsalis pedis pulse every 15 minutes (because circulation) A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? Offer high-calorie, high protein snacks to the client A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? Autonomy Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client's own best interest A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? Check the mouth for smooth and smoky breath - airway obstruction via foreign body A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow