NCLEX Passpoint Exam (Latest 2024/ 2025 Update) With Questions and Verified Answers| | 100, Exams of Nursing

Download NCLEX Passpoint Exam (Latest 2024/ 2025 Update) With Questions and Verified Answers| | 100 and more Exams Nursing in PDF only on Docsity! NCLEX Passpoint Exam (Latest 2024/ 2025 Update) With Questions and Verified Answers| | 100% Correct | Grade A+ A nurse is caring for a client with schizophrenia whose symptoms are managed with medications. The client reports feeling so well that the medications are no longer needed.. Which response indicates that the nurse understands the client's diagnosis? "The medications are helping you. If you suddenly stop taking them, you could get sick again." "You should take the medication for several months after you go home." "I'll pass this information on to your physician to see if the physician feels this might be wise." "You have to take the pills the physician has ordered for you." - ✔✔"The medications are helping you. If you suddenly stop taking them, you could get sick again." A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? "Signing an advance directive now will help ensure that my family and care team know what I want when I'm eventually unable to make decisions." "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens." "My family will take care of me. I've given my daughter durable power of attorney for health care." "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." - ✔✔"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens." During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform related to documentation? Include the time and date of the incident in the report. Highlight the mistake in the client record. Include the name of the nursing assistant in the report. Attach a copy of the finished report to the client record. - ✔✔Include the time and date of the incident in the report. Which would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia? Decrease the amount of protein in the diet. Receive prophylactic antibiotic therapy. Obtain influenza and pneumococcal vaccines. Seek prompt antibiotic therapy for viral infections. - ✔✔Obtain influenza and pneumococcal vaccines. A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle? the right to die autonomy of the client substituted judgment advance directive - ✔✔autonomy of the client A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into their teaching plan? impaired color discrimination increased appetite decreased hearing acuity - ✔✔decreased hearing acuity A child's most recent diagnostic testing reveals elevated levels of T3 and T4. When assessing this child for exophthalmos, the nurse should inspect what region? - ✔✔the eyes Which client statement indicates to the nurse that the client needs further teaching about disulfiram? "I'll read the labels on cough syrup and mouthwash for possible alcohol content." "A metallic or garlic taste in my mouth is normal when starting on disulfiram." "I can take disulfiram at bedtime if it makes me sleepy." "I can drink one or two beers and not get sick while on disulfiram." - ✔✔"I can drink one or two beers and not get sick while on disulfiram." Which nursing intervention is essential in caring for a client with compartment syndrome? keeping the affected extremity below the level of the heart wrapping the affected extremity with a compression dressing to help decrease the swelling starting an I.V. line in the affected extremity in anticipation of venogram studies removing all external sources of pressure, such as clothing and jewelry - ✔✔removing all external sources of pressure, such as clothing and jewelry The nurse manager is preparing to meet with several registered nurses (RNs) in the department to address practice issues. Which behavior by an RN will the nurse manager address as a violation of the RN's "duty to care"? fabricated assessment results in the medical record for an admitted client declined assignment to care for a client with dementia who was incontinent of stool shared confidential information about a hospitalized client on social media administered medications to a client in error that were intended for the client's roommate - ✔✔declined assignment to care for a client with dementia who was incontinent of stool 2/10180019-year-old client with mild concussion after slipping in school parking lot three hours prior. No loss of consciousness. No appreciable neurological deficits. CT scan normal. Client was preparing for discharge. Now reports a 5/10 headache. Acetaminophen PO prescribed.When offered acetaminophen, the client's parents tell the nurse that they would like their child to have something stronger. What is the nurse's best response? "We avoid giving aspirin to children and young adults because of the danger of Reye syndrome." "Opioids are avoided following a head injury because they may hide a deteriorating condition." "Stronger medications may lead to vomiting, which increases the intracranial pressure." "Acetaminophen is strong enough for your child's mild concussion." - ✔✔"Opioids are avoided following a head injury because they may hide a deteriorating condition." For the client with a substance abuse problem, which intervention would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs? recreation individual therapy solitary activities group sessions - ✔✔group sessions A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions? The client will be able to problem solve in situations on the psychiatric unit. The client will be oriented to person, place, and time. The client will be free from anxiety and be able to use self-calming techniques before reaching panic level. The client will show no self-harm or harm to staff. - ✔✔The client will show no self-harm or harm to staff. A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind? Family caregivers are always perceived to be supportive of good care. The current reimbursement system recognizes the family's nontechnical value priorities. The nurse needs to be creative in integrating the technical and relational aspects of care. Nurses should avoid asking the family caregivers to conduct the skilled task. - ✔✔The nurse needs to be creative in integrating the technical and relational aspects of care. An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Which anticipatory guidance for the parents and adolescent is most important? technique for monthly testicular self-examinations the adolescent's sterility the adolescent's future plans need for a lot of psychological support - ✔✔technique for monthly testicular self-examinations The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? Return the residual and begin the feeding. Hold the feeding and recheck the residual in 4 hours. Discard the residual and subtract the residual amount from the feeding. Administer an amount of water equivalent to the feeding. - ✔✔Return the residual and begin the feeding. Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts: provide for permanent wound closure. promote the growth of epithelial tissue. encourage formation of tough skin. facilitate development of subcutaneous tissue. - ✔✔promote the growth of epithelial tissue. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. A 7-year-old child is admitted to the hospital with acute rheumatic fever. During the acute phase of the illness, which diversional activity would the nurse most discourage? playing with a doll with the nurse watching the television with a sibling reading a book with the father playing checkers with a roommate - ✔✔playing checkers with a roommate School-aged children enjoy board games and are commonly intense about following rules. Their play can become emotional. Adequate rest is of utmost importance during the acute stage of rheumatic fever. Therefore, playing a game with another child probably would be too strenuous. Such diversional activities as reading a book, playing with a doll, and watching television would be more satisfactory. The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? policies from other hospitals data from retrospective studies expert opinions published national standards - ✔✔published national standards Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies. A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply. eat a large meal and drink fluids before bedtime keep the room very warm avoid caffeine, alcohol, and nicotine before bedtime schedule bedtime when you feel tired participate in a bedtime routine prepare the room for sleep and turn off distracting noise - ✔✔avoid caffeine, alcohol, and nicotine before bedtime prepare the room for sleep and turn off distracting noise participate in a bedtime routine A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response? "The baby has had a bowel movement, indicating severe fetal distress." "This is a routine assessment and your baby is fine." "The baby has had a bowel movement, indicating mild fetal distress." "The baby needs to be observed more closely." - ✔✔"The baby needs to be observed more closely." A nurse should expect a client with hypothyroidism to report increased appetite and weight loss. thyroid gland swelling. nervousness and tremors. puffiness of the face and hands. - ✔✔puffiness of the face and hands. When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort? Activity intolerance Imbalanced nutrition: Less than body requirements Acute pain A client, who had intracavity radiation treatment for cervical cancer 1 month earlier, reports small amounts of vaginal bleeding. This finding most likely represents recurrence of the carcinoma. an expected effect of the radiation therapy. development of a rectovaginal fistula. infection secondary to a change in vaginal flora. - ✔✔an expected effect of the radiation therapy. After intracavity radiation, some vaginal bleeding occurs for 1 to 3 months. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, a nurse should instruct the client to push the control button at which time? at the beginning of each contraction at the beginning of each fetal movement at the end of fetal movement after every three fetal movements - ✔✔at the beginning of each fetal movement A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be most therapeutic? "Tumors are not always cancerous." "You sound concerned about what's happening." "You'll have to have some tests to rule out cancer." "Your healthcare provider can discuss this in more detail." - ✔✔"You sound concerned about what's happening." A young adult client who uses cannabis multiple times a day, has just participated in a family meeting at a community mental health center. The chart entry reads:2/100900The family meeting began by the client's family demanding that the client "stop using marijuana at once, or there will be severe consequences, including no support to attend college." The drug, and the problems associated with its use, were explained to the family.What educational topic should the nurse address with this family during the next teaching session? Discuss the possibility of the client developing violent tendencies. Talk about how things were prior to the client's substance use. Encourage the family to be more flexible with their thoughts and feelings. Address how the substance use has affected each member of the family. - ✔✔Address how the substance use has affected each member of the family. The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis? Exercise in cool temperatures. Take anti-inflammatory medications before exercising. Drink at least 2 quarts (1.9 liters) of fluids per day. Avoid contact sports. - ✔✔Drink at least 2 quarts (1.9 liters) of fluids per day. A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? Continue to assess the client, allowing the officer to assume responsibility for the handcuffs. Ask the physician for an order to remove the handcuffs. Call the supervisor and report the officer's decision to keep the handcuffs on. Refuse to provide care while the client is handcuffed to the stretcher. - ✔✔Continue to assess the client, allowing the officer to assume responsibility for the handcuffs. A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider? nails are thickened, brittle, and yellow urine output of 600mL/24 hours lower peripheral pulses +1 bilaterally increased sensitivity to glare - ✔✔urine output of 600mL/24 hours Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects? hypoglycemia constipation flulike symptoms retinopathy - ✔✔flulike symptoms After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? "I'll have to catheterize my pouch every 2 hours." "I'll have to wear an external collection pouch for the rest of my life." "I'll need to drink at least eight glasses of water a day." The family member of a client diagnosed with dissociative identity disorder (DID) asks a nurse if hypnotic therapy might help the client. How should the nurse respond? "No, hypnosis is rarely used in the treatment of DID." "Yes, but only after other types of therapy have failed." "No, hypnosis is a controversial treatment." "Yes, a client is often not consciously aware of alter personalities." - ✔✔"Yes, a client is often not consciously aware of alter personalities." A client with Parkinson's disease needs assistance with eating but does not require thickened liquids to aid swallowing. For what action by the unlicensed assistive personnel should the nurse intervene? allowing time between bites for the client to rest turning off the television when the client begins eating elevating the head of the client's bed to 45 degrees instructing the client to chew food thoroughly - ✔✔elevating the head of the client's bed to 45 degrees A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which type of burns does the nurse determine are present? third degree (full thickness) first degree (superficial) fourth degree (full thickness that includes fat, fascia, muscle, and/or bone) second degree (partial thickness) - ✔✔third degree (full thickness) The most effective health-promotion measure related to glaucoma that the nurse could teach clients is: prompt treatment of all eye infections. avoidance of extended-wear contact lenses by older people. appropriate blood pressure control. annual intraocular pressure measurements for people older than 40 years. - ✔✔annual intraocular pressure measurements for people older than 40 years. People who are at risk for developing glaucoma, such as those with diabetes or hypertension, African ancestry, and a family history of glaucoma, should have their intraocular pressure checked annually after 35 years of age. The nurse is performing wound care on a client with an open fracture. What is the nurse's priority action to clean the wound? Apply antibiotic ointment to the site. Irrigate the wound with normal saline. Administer ordered pain medication. - ✔✔Irrigate the wound with normal saline. A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure (IOP) with a tonometer. Which statement about this procedure is true? The tonometer will register the force required to indent or flatten the corneal apex. The client should wear dark glasses for several hours after the procedure. The client will direct the gaze forward while the physician rests the tonometer on the scleral surface. A topical anesthetic will be administered after the examination. - ✔✔The tonometer will register the force required to indent or flatten the corneal apex. The tonometer will register the force required to indent (using Schiotz's tonometer) or flatten (using an applanation tonometer) the corneal apex. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? "I should eat foods rich in protein." "I can still drink coffee and tea in moderation." "I should increase my fluid intake." "I'll enroll in an aerobic exercise program." - ✔✔"I can still drink coffee and tea in moderation." A client claims to have a "special mission from God". The nurse incorporates this religious delusion of grandeur into the client's plan of care based on the understanding that the primary purpose of such a delusion is to provide: comfort. safety. survival. self-esteem. - ✔✔self-esteem. The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer's dementia. During the visit, the nurse notes bruising on the client's face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse's responsibility in this situation? Select all that apply. Monitor the situation during the subsequent home visits. Report the suspicion to the local Adult Protective Services Agency within 24 hours. Do nothing because the nurse has no proof of actual wrongdoing or abuse by anyone. color and clarity of fluid fetal heart rate (FHR) and pattern before and after the procedure odor and amount of fluid A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment. All options must be used. 3Ask the client to urinate. 1Auscultate the client's abdomen. 4Percuss the client's abdomen. 2Perform light palpation. - ✔✔Ask the client to urinate. Auscultate the client's abdomen. Percuss the client's abdomen. Perform light palpation. Which suggestions should the nurse include when teaching the parents of a child who has viral tonsillitis? Select all that apply. Give acetaminophen for sore throat. Supply a regular diet. Offer cough medicine every 4 hours. Gargle with warm salt water. Offer lots of fluids. Administer aspirin for fever control. - ✔✔Gargle with warm salt water. Give acetaminophen for sore throat. Offer lots of fluids. A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than 0.5. 0.21. 0.7. 0.35. - ✔✔0.5. A client has a chest tube attached to suction. Which interventions would the nurse perform? Select all that apply. Change the dressing as ordered using aseptic technique. Mark the amount of drainage in the chamber at the end of the shift. Clamp the chest tube when suctioning the client. Position the client on the side to apply pressure to the chest tube site. Palpate the surrounding area of the chest tube for crepitus. - ✔✔Change the dressing as ordered using aseptic technique. Palpate the surrounding area of the chest tube for crepitus. Mark the amount of drainage in the chamber at the end of the shift. A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain? parietal temporal occipital frontal - ✔✔temporal A nurse is working with a client on recognizing the relationship between alcohol use and interpersonal problems. What is the nurse's priority intervention for this client? Help the client recognize personal strengths. Have the client work with peers who can serve as role models. Have the client identify compulsive behaviors. Encourage the client's use of defense mechanisms. - ✔✔Help the client recognize personal strengths. The client's outcomes are best promoted if the nurse engages the client from a strengths-based approach The nurse is teaching the parents of a young child who had surgery to form a colostomy what to expect when the child goes home. The parents express concern about the appearance of the stoma. Which of the following is the most appropriate response by the nurse? "The stoma will change to a flesh color after three months." "The size of the new stoma should stabilize in 6-8 weeks." "Children have a difficult time accepting a stoma." "You can use a skin barrier to cover the appearance of the stoma." - ✔✔"The size of the new stoma should stabilize in 6-8 weeks." After a cholecystectomy, the client is to follow a low-fat diet. Which food would be most appropriate to include in a low-fat diet? roast beef sandwich with lettuce and tomato cheese omelet with onions peanut butter on wheat toast ham salad sandwich made with mayonnaise - ✔✔roast beef sandwich with lettuce and tomato When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of cereals and grains. dairy products. fresh fruits. processed meats. - ✔✔fresh fruits. To treat a child's atopic dermatitis, a physician orders a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching? "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." "I will gently scrape the skin before applying the cream to promote absorption." "I will apply a moisturizing cream sparingly and will wash the affected area frequently." "I will spread a thick coat of hydrocortisone cream on the affected area and will wash this area once a week." - ✔✔"I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." The husband of a client with cervical cancer says to the nurse, "The doctor told my wife that her cancer is curable. Is he just trying to make us feel better?" Which would be the nurse's most accurate response? "Saying a cancer is curable means that 50% of all women with the cancer survive at least 5 years." "When cervical cancer is detected early and treated aggressively, the cure rate is almost 100%." "The 5-year survival rate is about 75%, which makes the odds pretty good." "Cancers of the female reproductive tract tend to be slow-growing and respond well to treatment." - ✔✔"When cervical cancer is detected early and treated aggressively, the cure rate is almost 100%." A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply. "I will notify my health care provider if experiencing increased fatigue or muscle weakness." "If I forget a dose, I will catch-up by doubling the next dose." "I will take the digoxin at 9 AM daily." "I will take my pulse before each dose of digoxin." "I will take the digoxin with my antacids at night." "I understand that I will need annual blood work to check therapeutic levels." - ✔✔"I will take the digoxin with my antacids at night." "If I forget a dose, I will catch-up by doubling the next dose." "I understand that I will need annual blood work to check therapeutic levels." A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? asking an interpreter to relay the instructions to the client asking frequently whether the client understands the instructions demonstrating the procedure and having the client return the demonstration writing out the instructions and having a family member read them to the client - ✔✔demonstrating the procedure and having the client return the demonstration A home care nurse is assessing a new client whose albumin level is 1.5 g/dL (15 g/L) and whose body weight is 25% below the ideal weight. What action should the nurse take? Perform capillary refill time assessment. Perform 3-day diet recall with client. Obtain order for enteral feedings. Obtain order for total protein level. - ✔✔Perform 3-day diet recall with client. A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply. effectiveness of prior dose of medication client's most current height and weight type of medication the client has been taking client's pain level on a scale of 1 to 10 client's reaction to the previous dose administration time of the last dose - ✔✔administration time of the last dose client's pain level on a scale of 1 to 10 type of medication the client has been taking client's reaction to the previous dose effectiveness of prior dose of medication serum calcium level of 7.5 mg/dl (1.9 mmol/L) Bence Jones protein in the urine serum creatinine level 0.5 mg/dl (44.2 mcmol/L) serum protein level 5.8 g/dl (58 g/L) - ✔✔Bence Jones protein in the urine The presence of Bence Jones protein in the urine almost always confirms multiple myeloma. On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. What should the nurse do next? Encourage the client to take more ice chips. Notify the health care provider (HCP). Ask another nurse to validate the absence of bowel sounds. Document assessment findings in the client's medical record. - ✔✔Document assessment findings in the client's medical record. A client is prescribed a bisacodyl suppository. When administering the suppository, the nurse will include what actions? Position client on the right side in Sim's position to ensure the flexure of the rectum is at the proper angle for insertion. Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter. Have client sit on a commode or toilet immediately after the insertion of the suppository to prevent incontinence. Ensure the suppository is in direct contact with the stool in the rectum to facilitate mechanism of action. - ✔✔Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter. A client has undergone total gastrectomy due to stomach cancer. Which nursing interventions are necessary for this client immediately after surgery? Select all that apply. Irrigate and reposition the nasogastric (NG) tube if drainage is minimal. Maintain the client in a supine position. Encourage incentive spirometry use every hour during the client's waking hours. Administer opioid analgesics as prescribed. Observe the wound for redness, swelling, and warmth. - ✔✔Observe the wound for redness, swelling, and warmth. Encourage incentive spirometry use every hour during the client's waking hours. Administer opioid analgesics as prescribed. A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm? pulmonary edema stroke cardiac tamponade myocardial infarction - ✔✔cardiac tamponade The client presents to the clinic with severe anemia, and is a Jehovah's Witness with religious beliefs that prohibit the administration of blood products. Which concurrent medications does the nurse teach the client about when receiving blood products? Select all that apply. epoetin alfa NSAIDs ferrous sulfate aspirin levothyroxine - ✔✔epoetin alfa ferrous sulfate After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. The client is incontinent and has a tarry stool. Their blood pressure is 90/50 mm Hg, and hemoglobin is 10 g. Which nursing intervention is a priority for this client? performing range-of-motion (ROM) exercises on the left side elevating the head of the bed to 30 degrees checking stools for occult blood keeping skin clean and dry - ✔✔elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. The nurse is administering digoxin .125mg IVP to the client via healthcare provider's order. Which interventions should the nurse implement? Select all that apply. Call the nursing supervisor to clarify the order. Give the medication. problems with urinary and bowel elimination. Based on the client's assessment, the nurse would most likely initiate referrals to which discipline? Select all that apply. occupational therapy skilled nursing service home health aide speech therapy physical therapy - ✔✔physical therapy occupational therapy home health aide A registered nurse (RN) is assigning tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the client care team. Which task is restricted in terms of which care team member it could be delegated to? Select all that apply. administering oral pain medication to a postoperative client assisting a client to the bathroom who uses a walker for mobility assessing a client who just returned from cardiac catheterization providing oral care to a client who had nothing by mouth before surgery taking the health history of a newly admitted client - ✔✔administering oral pain medication to a postoperative client assessing a client who just returned from cardiac catheterization taking the health history of a newly admitted client A client loses control and throws two chairs toward another client. What should the nurse do next? Administer an oral PRN tranquilizer, and prepare for a show of determination. Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer. Process the incident with the client and discuss alternative behaviors. Ask the client to go to the quiet area and talk about the behavior. - ✔✔Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer. Which of the following situations does the nurse recognize as having the greatest risk for the fetus? a fetal heart rate of 170 bpm with fetal movements a gestational age of 37 weeks a breech lie a fundal height of 27 cm at 32 weeks gestation - ✔✔a fundal height of 27 cm at 32 weeks gestation Fundal height, measured in centimeters, should equal gestational weeks throughout the pregnancy (e.g., fundal height of 27 cm should occur at 27 weeks gestation). A fundal height of 27 cm at 32 weeks gestation is a very ominous finding that requires immediate attention and investigation. The nurse is instructing an unlicensed assistive personnel (UAP) on how to correctly position a client who has had a recent total hip replacement. In which position should the nurse tell the UAP to place the affected leg when the client is lying on the nonoperative side? abduction and extension adduction and extension adduction and flexion abduction and flexion - ✔✔abduction and extension A client is receiving a blood transfusion, and 1 hour after starting the transfusion the client reports dyspnea and has crackles on lung auscultation. Which medication would be most important for the nurse to give? acetaminophen 600 mg PO diphenhydramine 50 mg PO furosemide 40 mg I.V. methylprednisolone 250 mg I.V. bolus - ✔✔furosemide 40 mg I.V. After the nurse instructs a client who is scheduled for in vitro fertilization (IVF) about the procedure, which statement by the client indicates to the nurse that the instructions have been successful? "I will need to receive a series of estrogen injections after I have the procedure." "After fertilization, three or four embryos will be transferred through the cervix." "My risk for multiple births is lower with this procedure than with the gamete intra-fallopian transfer procedure." "I know that the chances of getting pregnant with this procedure are about 50%." - ✔✔"After fertilization, three or four embryos will be transferred through the cervix." A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The client undergoes biopsies of facial lesions. The preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate? Inform the client of the biopsy results and support them emotionally. Tell the client that Kaposi's sarcoma is common in people with AIDS. Explore the client's feelings about the facial disfigurement. Pretend not to notice the lesions on the client's face. - ✔✔Explore the client's feelings about the facial disfigurement. The therapeutic team has identified the need to formulate strategies to maintain a safe environment for a client with schizophrenia displaying inappropriate behavior. Which strategy must be initiated immediately? Monitor the client's behavior. Teach appropriate ways to communicate and interact with others. Identify the client's thought process that leads to the client's behavior. Explore with the client's reasons for demonstrating this behavior. - ✔✔Monitor the client's behavior. The unit must be maintained as a safe environment for the client and the other clients; therefore, the client should never have unsupervised time on the unit. After the administration of t-PA, the assessment priority is to: Monitor breath sounds. Monitor the 12-lead electrocardiogram (ECG) every 4 hours. Monitor for fever. Observe the client for chest pain. - ✔✔Observe the client for chest pain. observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? administers adenosine as a rapid I.V. push over 2 seconds to a client with supraventricular tachycardia turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation administers diltiazem to a client with atrial fibrillation administers lidocaine to a client experiencing frequent premature ventricular contractions (PVCs) - ✔✔turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation A client diagnosed with rheumatoid arthritis reports that pain and stiffness are worse when arising in the morning. What interventions can the nurse suggest to assist the client in decreasing the pain? Select all that apply. splint the joints in the same position adaptive equipment around the clock opioids for pain hot bath to alleviate stiffness energy conservation techniques - ✔✔energy conservation techniques adaptive equipment hot bath to alleviate stiffness In setting goals for a client with advanced liver cancer who has poor nutrition, which is a desired outcome for the client? The client will have normalized albumin levels. The client will gain 1 lb (0.5 kg) every 2 weeks. The client will return to ideal body weight. The client will maintain current weight. - ✔✔The client will maintain current weight. A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first? Assess for hypotension. Logroll the client to see if he is lying on a foreign object. Raise the head of the bed. Check the client for a distended bladder. - ✔✔Raise the head of the bed. When the client demonstrates clinical manifestations of autonomic dysreflexia, the nurse should first elevate the head of the bed immediately to decrease the intracerebral pressure caused by the hypertension that developed from autonomic stimulation The nurse has administered meperidine to a client in labor. Which change in the fetal heart rate tracing would the nurse expect to occur as a result of the meperidine administration? early decelerations decreased fetal heart rate variability fetal bradycardia repetitive late decelerations - ✔✔decreased fetal heart rate variability A nurse strives daily to provide competent care and make moral choices in the practice of nursing. Which behaviors demonstrated by the nurse exemplify the moral choices in practice? Select all that apply. receiving baked goods from a client's family for care rendered providing in-service education for staff to advance up the clinical ladder spending time caring for a client and receiving no acknowledgement for the effort coming in to work an extra shift to receive an incentive bonus delivering the same quality care while working overtime due to a staffing shortage - ✔✔delivering the same quality care while working overtime due to a staffing shortage Amphetamines, including cocaine, cause pupils to dilate. The nurse is working on a labor and delivery unit, and is precepting a new graduate nurse. The graduate asks the preceptor, "Is oxytocin used for pain in labor and delivery?" What is the best response by the preceptor? Select all that apply. "Oxytocin is used to control postpartum bleeding." "Oxytocin is used for labor induction." "Oxytocin is used to stimulate breast milk ejection." "Oxytocin is used to prevent pregnancy." "Oxytocin is used for amenorrhea." - ✔✔"Oxytocin is used to control postpartum bleeding." "Oxytocin is used to stimulate breast milk ejection." "Oxytocin is used for labor induction." The emergency-room nurse is caring for a trauma client with the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? Metabolic acidosis with a compensatory respiratory alkalosis Metabolic alkalosis with a compensatory alkalosis Metabolic acidosis with no compensation Respiratory acidosis with no compensation - ✔✔Metabolic acidosis with a compensatory respiratory alkalosis The nurse in an inpatient psychiatric adult unit is assigned care for a group of clients. Which client would the nurse see first during morning rounds? client with depression who refused medications last evening and will not get out of bed client with schizophrenia scheduled to be discharged today client admitted to the hospital for agitation and paranoia client with advanced dementia who has not communicated in the 2 days since arriving on the unit - ✔✔client admitted to the hospital for agitation and paranoia The nurse is caring for a group of clients. Which client should the nurse see first? a client with new onset of atrial fibrillation who has a heart rate of 95 a client with stable angina who took one sublingual nitroglycerine 30 minutes ago a client with a placement of a coronary artery stent 30 minutes ago a client with a history of sinus tachycardia who is to receive a beta-blocker - ✔✔a client with stable angina who took one sublingual nitroglycerine 30 minutes ago A client has a plaster cast applied to the lower extremity that is still wet to touch. In which way should the nurse move the casted limb to elevate it on a pillow? Lift the limb from the knee. Place the palms on both sides of the cast. Place the fingers around the cast. Lift the limb from the ankle. - ✔✔Place the palms on both sides of the cast. A primigravid client is seen for her first visit in the antenatal clinic and tells the nurse that her brother was born with cystic fibrosis (CF). When teaching the client about this disorder, the nurse should include which information? Select all that apply. Persons of Asian descent have the highest inheritance rates. Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the disease. Fetal testing can occur by checking the shape of the red blood cells. To inherit CF, each parent must carry a recessive trait for the disease. If both parents carry the trait, each offspring has a 25% chance of inheriting the disease. - ✔✔To inherit CF, each parent must carry a recessive trait for the disease. If both parents carry the trait, each offspring has a 25% chance of inheriting the disease. Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the disease. The nurse is instructing a client who will have a total hip replacement tomorrow. Which information is most important to include in the teaching plan at this time? Show the client what an actual hip prosthesis looks like. Teach how to prevent hip flexion. Demonstrate coughing and deep-breathing techniques. Assess the client's fears about the procedure. - ✔✔Assess the client's fears about the procedure. When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the client's diet? Select all that apply. Offer small, frequent, light meals 5-6 times daily. Offer cool drinks and foods as tolerated. Administer oral anesthetic 15 minutes prior to meals. Schedule a large lunch with a nutritious snack for dinner. Encourage a favorite meal of pizza and wings. Schedule high-nutrient shakes between meals. - ✔✔Schedule high-nutrient shakes between meals. Offer small, frequent, light meals 5-6 times daily. A client with metastatic ovarian cancer is ordered cisplatin. Before administering the first dose, the nurse reviews the client's medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin? erythromycin an aminoglycoside a cephalosporin a tetracycline - ✔✔an aminoglycoside An aminoglycoside may cause nephrotoxicity and ototoxicity when given concomitantly with cisplatin. A client with right lower quadrant pain is admitted to the emergency department with a white blood cell (WBC) count of 17.8/mm3. What should the nurse do next? Notify the healthcare provider. Perform a complete abdominal assessment. Prepare the client for surgery. Assess vital signs. - ✔✔Assess vital signs. Which client does the nurse evaluate as having the highest risk of developing a postoperative wound infection? The client who had a perineal prostatectomy A postsurgical client following a radical prostatectomy The client who had a transurethral resection of the prostate A postsurgical client following a suprapubic prostatectomy - ✔✔The client who had a perineal prostatectomy The incision in a perineal prostatectomy is close to the rectum, which normally contains gram-negative organisms that can cause infection if introduced into other areas of the body. Therefore, a perineal incision can become contaminated more easily than those of the other procedures. A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults? follicular carcinoma medullary carcinoma papillary carcinoma anaplastic carcinoma - ✔✔papillary carcinoma Papillary carcinoma accounts for about 70% of thyroid cancer cases in adults. Follicular carcinoma accounts for roughly 15%; anaplastic carcinoma, about 5%; and medullary carcinoma, about 5%. A client with pulmonary fibrosis is prescribed home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use? hospital staff nurse respiratory rehabilitation assistant home health nurse social worker - ✔✔home health nurse A client has radiation seeds implanted into the prostate gland. Which action should the nurse take to safely provide care to this client? Select all that apply. Identify the safest amount of time to be at the bedside. Explain that the implanted seeds will be expelled through the urine. Place a permanent divider to shield the client in a semi-private room. Learn the safe distance from the client. Obtain the necessary shielding when providing care. - ✔✔Learn the safe distance from the client. Identify the safest amount of time to be at the bedside. Obtain the necessary shielding when providing care. A nurse is caring for a client in restraints on a psychiatric unit. Which nursing action would cause the charge nurse to intervene? placing two fingers between the restraint and the client's skin before securing to the bed frame removing the restraints and performing range-of-motion activities every 4 hours obtaining restraint orders every 24 hours from the healthcare provider tying a quick-release knot when securing the restraints - ✔✔removing the restraints and performing range-of-motion activities every 4 hours A nurse is caring for a client diagnosed with hepatic encephalopathy. Which sign or symptom would indicate that the disease is improving? Select all that apply. Serum ammonia levels are increased. The client is able to circle choices on the menu. The client is able to eat previously restricted food items. The electroencephalogram shows generalized slowing of brain waves. The nurse enters a client's hospital room and has difficulty identifying the hospitalized client among the six people in the room. The nurse is administering new medication. What are the nurse's best actions? Select all that apply Return to the room after the visitors leave. Ask the visitors to step out of the room. Ask the client to show his/her hospital name band. Ask the client to identify his/her name and date of birth. Assume the client is sitting on the bed. - ✔✔Ask the client to identify his/her name and date of birth. Ask the client to show his/her hospital name band. Ask the visitors to step out of the room. A nurse is caring for a client on life support in the cardiac care unit. The client's family, which is strongly religious, is unable to unanimously decide to remove life support. What should the nurse do? Select all that apply. Notify the hospital's ethics committee of the ethical dilemma. Supply the family with information and pamphlets on funeral services. Request pastoral services to assist the family in this decision. Ask the family to leave the unit to pray for a unified decision. Initiate family discussions around what the client would have wanted. - ✔✔Notify the hospital's ethics committee of the ethical dilemma. Request pastoral services to assist the family in this decision. Initiate family discussions around what the client would have wanted. A client with alcohol withdrawal syndrome is pulling at the central venous catheter, saying, "I'm swatting the spiders crawling all over me." What is the nurse's priority action? Encourage the client to rest. Tell the client there are no spiders. Explain that the client is pulling the I.V. tubing. Assign a nursing assistant to stay with the client. - ✔✔Assign a nursing assistant to stay with the client. A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness? lubricant jelly petroleum jelly antibiotic ointment sterile water - ✔✔lubricant jelly A nurse observes a hospitalized 10-month-old infant chewing on the security alarm attached to his identification bracelet. What intervention is most appropriate for the nurse to perform? Distract the infant with a more appropriate toy. Instruct the infant's parents regarding the safety hazard. Cover the device with gauze wrap so that it isn't visible. Remove the security device because it's a choking hazard. - ✔✔Distract the infant with a more appropriate toy. An unemployed client cannot afford prescription medications and has not taken the prescribed levothyroxine for some time. The client reports, "I've been getting sicker by the day." Which symptom is most likely related to not taking this medication? warm, dry, flushed skin diarrhea and vomiting tympanic temperature of 94° F (34.4° C) rapid heart rate - ✔✔tympanic temperature of 94° F (34.4° C) Hypothyroidism leads to a hypodynamic state, so a low body temperature is expected after the levothyroxine has been metabolized A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should wash their hands after touching the client. place the client in a private room. wear a mask when handling the client's bedpan. wear a gown when providing personal care for the client. - ✔✔wash their hands after touching the client. To maintain enteric precautions, the nurse must wash their hands after touching the client or potentially contaminated articles and before caring for another client. What occurs during the working phase of the nurse-client relationship? A nurse and a client discuss their feelings about terminating the relationship. A nurse and a client explore each others' expectations of the relationship. A nurse assesses a client's needs and develops a care plan. Ask the teacher if the child has had any urinary problems. Stay with the child, and allow her to sleep in a side-lying position. Awaken the child every 3 to 5 minutes to assess mentation. Perform a complete neurologic check every 3 to 5 minutes. - ✔✔Stay with the child, and allow her to sleep in a side-lying position During this time, the nurse should stay with the child, allowing sleep until she awakens. The side-lying position is best to prevent possible aspiration. The client is to have surgery on the fourth metatarsal. Identify the place on the illustration below where the client should confirm the operative site to the health care provider. - ✔✔ The parent of an autistic child visits the clinic and tells the nurse that her child has been acting out in school, particularly in the cafeteria and during gym class. Understanding that the child may be having difficulty with sensory processing, the nurse should suggest that the health care provider refer the child to which professional? physical therapist mental health provider occupational therapist speech language pathologist - ✔✔occupational therapist Occupational therapists can help evaluate sensory processing issues and fine motor difficulties. Many occupational therapists are also trained in coping strategies to help individuals feel more comfortable in their surroundings. While assessing a neonate 30 minutes after birth, the nurse observes that the child has a short neck covered with webbing. The nurse should further assess the client for which problem? cleft palate neural tube defects genetic deviations Potter's syndrome - ✔✔genetic deviations A client with congestive heart failure is admitted to the hospital. Which interventions should the nurse include in the plan of care to prevent skin breakdown? Select all that apply. Apply 2 liters of oxygen per nasal cannula if SaO2 < 93%. Encourage the client to ambulate three times a day. Apply heel protectors when lying in bed. Monitor vital signs every 4 hours. Weigh the client daily at the same time in the morning. - ✔✔Encourage the client to ambulate three times a day. Apply heel protectors when lying in bed. A neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse should take which action? Review the pregnancy and delivery history. Perform a full neonatal assessment. Check the neonate's blood glucose level. Call the pediatrician to report findings. - ✔✔Check the neonate's blood glucose level. The nurse is developing a plan of care for a 10-year-old child who is hospitalized with acute osteomyelitis. The leg is immobilized in a splint and there is swelling and tenderness of the proximal tibia. What is an appropriate expected outcome for this child? "The child will bear weight on the affected limb." "The child will ambulate with crutches." "The child will change position with minimal discomfort." "The child will participate in age-appropriate activities." - ✔✔"The child will change position with minimal discomfort." A nurse is caring for a client with pulmonary edema. The physician writes the accompanying orders. Which order should the nurse clarify? furosemide I.V. 40 mg every 6 hours 0.9% normal saline solution I.V. at 150 ml/hour dobutamine 5 mcg/kg/minute I.V. morphine I.V. 2 mg every 2 hours P.R.N. for shortness of breath - ✔✔0.9% normal saline solution I.V. at 150 ml/hour The nurse is preparing to help a client move up in bed with a goal of prevention of skin breakdown. Place the following steps in order for the procedure. All options must be used. 2Place a friction-reducing sheet under the client's midsection. 1Place the bed in the Trendelenburg position to prepare for the move. 3Have the client lift the head during the move. variance charting charting by exception focus charting problem, Intervention, Evaluation (PIE) charting - ✔✔charting by exception Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. A 19-year-old primigravid client has decided to breastfeed. Her 22-year-old husband supports her decision. The client tells the nurse, "My mother breastfed all of her children, but I'm going to need lots of help with breastfeeding. I'm worried that I won't be able to do this." What additional information should the nurse obtain prior to teaching the client about breastfeeding? Ask the client if she has read any literature about breastfeeding. Perform a complete physical examination to determine her need for help. Assess her body-to-fat ratio and nutritional status before beginning breastfeeding. Determine the client's level of motivation to breastfeed. - ✔✔Determine the client's level of motivation to breastfeed. A nurse is preparing to help a client with weakness in the right leg move from the bed to a wheelchair. Where should the nurse place the chair? Perpendicular to the bed on the right side 45 degrees to the bed on the left side 45 degrees to the bed on the right side - ✔✔45 degrees to the bed on the left side The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall. According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal for the debriefing? improving the staff's use of restraint procedures deciding when to release the client from restraints providing feedback to each other on how procedures were handled comparing the perceptions of the various staff members - ✔✔improving the staff's use of restraint procedures A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Encourage the mother to breast-feed because the neonate is becoming dehydrated. Provide blow-by oxygen and monitor the neonate's respiratory status. Keep the neonate in the nursery, monitor vital signs every 2 hours, and inform the physician of the neonate's status when the physician mak - ✔✔Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Provide blow-by oxygen and monitor the neonate's respiratory status. Inform the parents that she wants to monitor the neonate closely. A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through absorption through the gloves. absorption through the gown. inhalation of aerosols. absorption through the goggles. - ✔✔inhalation of aerosols. Aerosol inhalation or absorption through the skin can cause accidental chemotherapy exposure When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply. Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret. Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. Child molesters resort to molestation because they have bad childhoods, so understanding that can help them decrease their molesting. Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. - ✔✔Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. This client is in crisis as a result of the traumatic stress of losing the partner. A traumatic event can create symptoms, such as difficulty eating, sleeping, and working. What is the most cost-effective suggestion for bereavement support for the hospice nurse to give a woman whose husband died 3 months ago and her three young children? Remind her gently that bereavement care before death minimizes grieving. Request individual counseling and medication to manage depression. Continue her bereavement support through hospice. Seek group counseling support for the three children. - ✔✔Continue her bereavement support through hospice. An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mm Hg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority? Give ibuprofen as ordered to reduce the fever. Encourage the client to cough and breathe deeply. Help the client get out of bed. Medicate the client for pain as ordered. - ✔✔Medicate the client for pain as ordered. A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to wear protective devices when exercising. wear worn, comfortable shoes. install safety devices in the home. get help when lifting objects. - ✔✔install safety devices in the home. A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? hypokalemia hyperkalemia hypocalcemia hypercalcemia - ✔✔hypokalemia The nurse should monitor the client receiving an I.V. infusion of terbutaline for hypokalemia, lactic acidosis, chest pain, arrhythmias, dyspnea, bloating, chills, or anaphylactic shock A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? Provide the client with written instructions about the importance of adherence to the treatment plan. Arrange for the client to pick up the medication in unit dose packaging at a local pharmacy. Arrange for the client to come to a community center each day to receive a meal and medication. Recommend having the client admitted to the hospital until the medication regimen is completed. - ✔✔Arrange for the client to come to a community center each day to receive a meal and medication. Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication. When formulating a plan of care for the postterm neonate at discharge, which outcome would be most appropriate? maintenance of a normal bilirubin level gain of 4 oz (120 g) by the time of discharge maintenance of normal body temperature establishment of a deep respiratory pattern - ✔✔maintenance of normal body temperature