NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS, Exams of Nursing

Download NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity!

COMPREHENSIVE QUESTIONS AND ANSWERS

NCLEX Review Study Guide Comprehensive 2023

A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client? - ANSWER "Have you tested your blood glucose?"

A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? - ANSWER 1670mL

A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first: - ANSWER Raise the head of the client's bed

A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? - ANSWER Hearing loss

Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? - ANSWER Every morning before breakfast, with a full glass of water

A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume: - ANSWER Apple juice

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? - ANSWER Recent stroke

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse

COMPREHENSIVE QUESTIONS AND ANSWERS

expect the client to exhibit? Select all that apply. - ANSWER Nausea

Eye pain

Vomiting

Headache

The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client? - ANSWER Relief of anxiety

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? - ANSWER Administering 100% oxygen

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: - ANSWER Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening

A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to: - ANSWER Closely monitor the blood glucose level

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? - ANSWER Checking the client's blood pressure

A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: - ANSWER In about 6 weeks, when the vaginal vault is satisfactorily healed

A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: - ANSWER Ask the answering service to contact the on-call physician

A hospitalized female client with mania enters the unit community room and says

COMPREHENSIVE QUESTIONS AND ANSWERS

to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? - ANSWER "Don't say that. If you can't control yourself, we'll help you."

A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication? - ANSWER Intake and output

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. - ANSWER Fatigue

Low-grade fever

Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: - ANSWER Neck stiffness or soreness

A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: - ANSWER Stops the oxytocin infusion

A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: - ANSWER Pitting edema is present

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? - ANSWER Fever

A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next? - ANSWER Clamping the intravenous catheter

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. - ANSWER Seek medical advice if you find a skin lesion.

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? - ANSWER Dark urine

A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens? - ANSWER Abduction device

A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for: - ANSWER Seizure activity

A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? - ANSWER Checking the client's blood pressure

A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information? - ANSWER "I should drink a cup of coffee if I feel the urge to smoke."

A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis?

• ANSWER Atropine sulfate

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? - ANSWER "Let's talk about the information that you need to determine your risk of contracting HIV."

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: - ANSWER Sardines

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital sign must be checked before the medication is administered? - ANSWER Apical pulse

A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? - ANSWER "I need to participate in aerobic and weightlifting exercise three times a week."

A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? - ANSWER Maintaining cuff pressure

Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? - ANSWER Numbness and tingling of the fingers or toes

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply.

• ANSWER Smoking

High alcohol intake

White or Asian ethnicity

A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: - ANSWER Check for the presence of a gag reflex

A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that: - ANSWER Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts

Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to

COMPREHENSIVE QUESTIONS AND ANSWERS

the client about the medication and tells the client to: - ANSWER Increase fluid intake

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. - ANSWER Spinach

Legumes

Whole grains

A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description? - ANSWER Stable

A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: - ANSWER Improved swallowing function

A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child? - ANSWER Acetylcysteine (Mucomyst)

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? - ANSWER Anxiety

A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow

COMPREHENSIVE QUESTIONS AND ANSWERS

employee's hands were severed by a machine. What is the priority response by the nurse? - ANSWER Assessing the client for organic causes of loss of arm movement

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? - ANSWER Replacement of the uterus through the vagina into a normal position

A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: - ANSWER Conversion disorder

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: - ANSWER A lower abdominal incision

A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? - ANSWER Uteroplacental insufficiency during a contraction

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse - ANSWER Place small pieces of tape over the rough edges of the cast

A nurse developing a plan of care for a client with HIV infection identifies several

COMPREHENSIVE QUESTIONS AND ANSWERS

concerns. List them in order of priority, from highest to lowest. - ANSWER 1 Possible infection

2 Decreased nutrition

3 Fatigue

4 Despair

An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. - ANSWER 1 Use an otoscope to ensure that the tympanic membrane is intact.

2 Warm tap water to body temperature.

3 Fill an irrigating syringe with warm water.

4 Insert the irrigating solution by directing the solution toward the wall of the ear canal.

5 Document the completion of the procedure and how the client tolerated it.

The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? - ANSWER Checking for gastric residual volume and assessing tube placement

A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? - ANSWER "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"

A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take

COMPREHENSIVE QUESTIONS AND ANSWERS

from the medication supply room for intravenous (IV) administration? - ANSWER Regular (Humulin R)

A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? - ANSWER The pain is relieved by rest and nitroglycerin.

While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? - ANSWER Reed-Sternberg cells on biopsy of a lymph node

A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? - ANSWER Powerlessness

Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? - ANSWER "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."

A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. - ANSWER -Drink copious amounts of fluid and void frequently

-Avoid contact with any individual who has signs or symptoms of a cold

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of: - ANSWER Respiratory alkalosis

A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? - ANSWER Contacting the child's physician to report the findings

A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? - ANSWER "I need to keep any unopened bottles of insulin in the freezer."

A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would: - ANSWER Contact the physician

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? - ANSWER Decreased fluid volume

A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: - ANSWER Decrease

COMPREHENSIVE QUESTIONS AND ANSWERS

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? - ANSWER "The placenta maintains the body temperature of my baby."

A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? - ANSWER 28 mm Hg

Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: - ANSWER To contact the physician

A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: - ANSWER Identify the client's treatment goals

A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? - ANSWER Thyroid-stimulating hormone (TSH)

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? - ANSWER Epistaxis

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: - ANSWER July 2, 2013

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. - ANSWER "I need to avoid salt in my diet."

"It's fine to take any over-the-counter medication with the lithium."

"Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. - ANSWER Skin tenting

Flat neck veins

Weak peripheral pulses

Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: - ANSWER Levothyroxine amplifies the effect of warfarin sodium

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? - ANSWER Calcium gluconate

A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: - ANSWER Increase intake of high-fiber foods

COMPREHENSIVE QUESTIONS AND ANSWERS

The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately: - ANSWER Place some honey in her husband's mouth, between his gums and cheek

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. - ANSWER Fever

Vasculitis

Abdominal pain

A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client: - ANSWER That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity

A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? - ANSWER Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French.

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? - ANSWER Multiple sexual partners

A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician? - ANSWER Yellow skin

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important? - ANSWER Trapeze bar

A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? - ANSWER "I need to not drink coffee before the test."

A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately: - ANSWER Get into the shower and rinse the skin for at least 15 minutes

A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: - ANSWER Helping the woman empty her bladder

A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely? - ANSWER Bleeding

A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia? - ANSWER The client complains of a tingling sensation around the mouth.

A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid? - ANSWER High-impact exercise

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease?

• ANSWER "Do you have episodes of dizziness?"

A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to: - ANSWER Lie down to administer the subcutaneous injection

A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that: - ANSWER The client's hemoglobin level is low

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? - ANSWER "Have you ever worked in a mine?"

A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? - ANSWER Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain

A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: - ANSWER In a vertical position with the needles pointing up

COMPREHENSIVE QUESTIONS AND ANSWERS

Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication: - ANSWER 2 hours after meals

A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. - ANSWER Hunger

Weakness

Blurred vision

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? - ANSWER Placing the client in a lateral position with the bed flat

A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must: - ANSWER Contact the physician if the skin appears yellow

A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately: - ANSWER Encourage the child to drink water or milk in small amounts

A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first: - ANSWER Check the uterus and amount of lochia discharge

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? - ANSWER Spontaneous bruising

A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? - ANSWER A blood pressure higher than the normal range

A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication: - ANSWER With food

A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? - ANSWER Bilateral lung wheezes

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. - ANSWER Keep the volume of headphones at the lowest setting.

Avoid environmental conditions involving rapid changes in air pressure.

Clean the external ear and canal daily in the shower or while washing the hair.

The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: - ANSWER Document the laboratory result in the client's record

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? - ANSWER Soft, relaxed, nontender uterus

A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client: - ANSWER Is at low risk for AIDS

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? - ANSWER Cheeseburger

A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin (Lanoxin) 0.25 mg in the treatment of congestive heart failure (CHF). Which instructions should the nurse include on the list? Select all that apply. - ANSWER Take your pulse before taking each dose.

Take the digoxin at the same time each day.

Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances.

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply. - ANSWER -Ensuring that direct pressure is applied to the external hemorrhage site

-Ensuring a patent airway and supplying oxygen to the client as prescribed

-Inserting an intravenous (IV) catheter and administering fluids as prescribed

COMPREHENSIVE QUESTIONS AND ANSWERS

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: - ANSWER Assist in intubating the client and beginning mechanical ventilation

Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the: - ANSWER Albuterol several minutes before inhaling the fluticasone propionate

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: - ANSWER Depression

A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms? - ANSWER Obsessive-compulsive disorder

A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: - ANSWER Document the findings

A nurse is teaching a client with angina pectoris who is being discharged from the

COMPREHENSIVE QUESTIONS AND ANSWERS

hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching? - ANSWER "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work."

Although previously well controlled with glyburide (Diabeta), a client's fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? - ANSWER Lithium carbonate (Lithobid)

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? - ANSWER "I need to stop the medication and call my doctor if I have severe diarrhea."

A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client? - ANSWER Pleuritic chest pain

A nurse provides dietary instructions to a client with osteoporosis who has sustained a fracture about foods that will promote healing. The nurse tells the client that it is best to consume foods that are high in: - ANSWER Vitamin C

Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication?

• ANSWER Checking the client's blood pressure

A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to: - ANSWER Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate (DDAVP) by way of the nasal route. For which of the following occurrences does the nurse tell the client to contact the physician? - ANSWER Headache and nausea

A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? - ANSWER Establish a trusting nurse-client relationship

A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated? - ANSWER The client takes isosorbide dinitrate (Isordil).

The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to: - ANSWER Check the drainage for glucose

Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications? - ANSWER "Does your child have an allergy to peanuts?"

A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? - ANSWER "I need to contact my surgeon immediately if I feel any numbness in my genital area."

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the

COMPREHENSIVE QUESTIONS AND ANSWERS

nurse include? Select all that apply. - ANSWER Use a straw to drink.

Use caution when leaning forward or backward.

Do not drive, because full range of vision is impaired with the device.

A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: - ANSWER Document the findings

Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? - ANSWER The client takes a prescribed antihypertensive.

A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? - ANSWER Documenting the finding

Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: - ANSWER Tomato juice

A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? - ANSWER Notifying the physician

A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? - ANSWER Fowler's position

COMPREHENSIVE QUESTIONS AND ANSWERS

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: - ANSWER Helps predict the risk for the development of chronic complications of diabetes mellitus

Levothyroxine (Synthroid) is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the physician's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that: - ANSWER The full therapeutic effect may take 4 weeks

Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication? - ANSWER Spinach

A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: - ANSWER Take the medication with food

A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client? - ANSWER Stokes sign

A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? - ANSWER White blood cell count of 2500 cells/mm3

A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate

COMPREHENSIVE QUESTIONS AND ANSWERS

that the condition has not yet resolved? Type the option number that is the correct answer. - ANSWER 1

Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose? - ANSWER Maintaining the client on bed rest for 3 hours

A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: - ANSWER Physical and functional abilities

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? - ANSWER Count wet diapers to be sure that the infant is having at least six to 10 each day

A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that: - ANSWER The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage - ANSWER Notifies the emergency department physician

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? - ANSWER Flulike pulmonary symptoms

COMPREHENSIVE QUESTIONS AND ANSWERS

A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that: - ANSWER Her hair may fall out but will regrow after the chemotherapy is discontinued

A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which of the following findings indicates to the nurse that the client has sustained flail chest? - ANSWER Asymmetrical chest movement

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? - ANSWER "Are you having any difficulty hearing?"

A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: - ANSWER Herbs and spices

A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? - ANSWER Reddish lochia on postpartum day 8

The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next? - ANSWER Assessing the wound

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the