NCLEX-RN Practice Questions: Comprehensive Review for Nursing Exams, Exams of Nursing

Download NCLEX-RN Practice Questions: Comprehensive Review for Nursing Exams and more Exams Nursing in PDF only on Docsity! NCSBN NCLEX QUESTIONS FINAL EXAM WITH ACCURATE ANSWERS [UPDATED AND GRADEDA+][2024-2025] 1. A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem: 4 Explore for further identification about the nature of the problem 2. The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember.": 3 3. The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area: 1An open wound on the heel with minimal discomfort- 4. A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs? 1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear 2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine 3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries: 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - 5. A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome? 1. Varicella 2. Meningitis 3Risk for infection - 4Altered tissue perfusion: 3 11.A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child? 1Hypothermia 2Nausea and vomiting 3Hypoventilation 4Bradycardia: 2 12.A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure? 1Place the hands or a folded blanket under the head of the child 2Provide privacy as much as possible to minimize frightening the other chil- dren 3Move any chairs or desks at least three feet away from the child 4Note the sequence of movements with the time lapse of the event: 1Place the hands or a folded blanket under the head of the child - 13.A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client? 1Droplet 2Contact 3Standard 4Airborne: 4 14.A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)? 1"I have active tuberculosis." 2"I have been exposed to mycobacterium tuberculosis." 3"I have never been infected with mycobacterium tuberculosis." 4"I have never had tuberculosis.": 2 15.A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment? 1Wheezes 2Friction rubs 3Rhonchi 4Diminished sounds: 3 16.A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use? 1Listen quietly without comment 2Ask for further information on the spies 3Confront the client about the delusions 4Contact security for potential safety concerns: 1Listen quietly without comment - 17.Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? 1Less jaundice 2Increased appetite 3Decreased lethargy 4Less edema: 3 18.The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?": 2 24.A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust: 3 25.The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles: 1Squeeze the trapezius muscle firmly - 26.A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy? 1Discontinue breastfeeding during treatment 2Rotate the neonate to treat all of his/her skin 3Restrict holding the newborn during treatment 4Provide more frequent feedings: 4Provide more frequent feedings- 27.A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond? 1"You seem to be in a bad mood." 2"Perfect? I don't quite understand." 3"You sound angry right now." 4"That explains why you've been staring at me.": 3 28.The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? 1It can cause severe headaches 2It may no longer work as well 3It will cause profound hypotensive effects 4it will irritate the skin: 2 29.A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? 1Compare daily infant weights 2Monitor the infant's urine output 3Ensure appropriate fluid intake 4Maintain accurate intake and output: 2 30.A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? 1They can expect the child will be mentally retarded 2Administration of a thyroid hormone will prevent problems 3This rare condition is hereditary 4Physical growth and development will be delayed: 2 31.A child is admitted to the hospital for emergency surgery. The child's par- ent reports several allergies. Which of these allergies should all the operative health care personnel be notified about? 1Perfumed soap 2Shellfish 3Balloons 4Mold: 3 of which phase in the therapeutic relationship? 1Termination 2Working - 3Orientation 4Pre-interaction: 2 38.The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers? 1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours 2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years 3Obese client who uses a wheelchair throughout the facility 4Malnourished older adult client who is on bed rest: 4 39.A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status? 1Glasgow Coma Scale 13, no ventilator required 2Glasgow Coma Scale 8, respirations regular - 3Appears to be sleeping, vital signs stable 4Comatose, breathing unlabored; is resting: 2 40.A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time? 1Notify the health care provider of the client's failure to follow the prescribed diet 2Make a referral to Meal-on-Wheels for delivery of one meal three times a week 3Discuss the diet with the client to learn the reasons for not following the diet - 4Recommend a release from home health care related to noncompliance: 3 41.A client has chronic renal failure and is being treated at home. During week- ly home visits, which factor is the most accurate indicator of fluid balance? 1Trends in daily weights - 2Skin turgor over at least two areas of the body 3Changes in mucous membrane moistness 4Difference between intake and output: 1Trends in daily weights - 42.The client is receiving a thrombolytic agent to open a clot-occluded coro- nary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? 1Hematemesis - 2Pink- tinged saliva 3Serosanguinous drainage from the IV site 4Slight rust-colored urine: 1Hematemesis - 43.The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? 1Check the distal circulation of the casted extremity 2Obtain the pulse oximetry reading 3Measure the client's blood pressure in the supine and Fowler's positions 4Check the orientation to time, place and person: 2 44.The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shift: 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Spare protein catabolism to meet metabolic and healing needs 4 stimulate increased peristalsis and nutrient absorption: 3 50.A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority com- ment made by the nurse? 1"Use this medication at bedtime to promote rest." 2"Notify the health care provider if your canister lasts only two weeks." 3"Inhale this medication after other asthma sprays." 4"Discontinue the inhaler if you are dizzy.": 2 51.An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deterio- rates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? 1Notify the attending physician 2Consult the charge nurse and prepare to transfer the client to an intensive care unit 3Call the rapid response team 4Contact the family member indicated in the admission forms: 1 52.The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care? 1Safety 2Elimination 3Rest 4Nutrition: 1 53.A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance? 1Iron 2Calcium 3Vitamin E 4Vitamin K: 4 54.The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase? 1The client revitalizes a relationship with the family to help in coping with a child's death 2The client recognizes feelings and expresses them appropriately 3The client expresses a desire to be mothered and pampered 4The client recognizes regression as a part of a defense mechanism: 2 During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. 55.During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately.: An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf 56.A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion? 1Proximity to emergency services 1"Be sure to eat a fat-free diet until the test, and drink lots of water." 2"Stay at the laboratory so that two blood samples can be drawn an hour apart." 3"Do not eat or drink anything but water for 12 hours before the blood test." 4"Have the blood drawn within two hours of eating breakfast.": 3 63.The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adoles- cent? 1Restricted physical activity 2Separation from family 3Altered body image 4Unrelieved pain: 3 64. In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect? 1Retained placenta 2Clotting disorder 3Vaginal lacerations 4Uterine atony: 3 65.A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus? 1High-protein diet 2Fluid intake of at least 3000 mL/day 3Acetaminophen for inflammation 4Hot compresses to affected joints: 2 66.A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client? 1Weigh the child twice per shift 2Relieve boredom through physical activity 3Institute seizure precautions 4Encourage the child to eat protein-rich foods: 3 67.A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age? 1Riding a tricycle 2Tying shoelaces 3Jumping rope 4Playing hopscotch: 1 68.The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? 1Jaundice 2Peripheral edema 3Buffalo hump 4Increased muscle mass: 3 69.A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach? 1Commenting "I believe you know better than to eat with your hands." 2Removing the food and stating "You can't have any more food until you use the spoon." 3Jokingly stating "Well, I guess fingers sometimes work better than spoons." 4Placing the spoon in the client's hand and stating "Use the spoon to eat your food.": 4 70.The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? 1Monitor serum electrolytes and creatinine 2Measure apical pulse prior to administration 3Maintain accurate intake and output ratios 4Monitor blood pressure every 4 hours: 2 76.The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? 1Jaundice 2Anorexia 3Hematemesis 4Ascites: 3 77.A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose? 1Foster independence with better communication 2Protect the ego and diminish anxiety 3Eliminate anxiety and apprehension 4Avoid conflict and unpleasant consequences: 2 78.A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? 1Pinworm 2Scabies 3Ringworm 4Allergies: 1 79.The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse? 1Administer PRN pain medication as ordered 2Determine the origin of the pain 3Draw blood for for troponin/CK and CBC per standing orders 4Order ECG per standing orders: 1 80.The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention? 1Allow the client the time needed to dress 2Encourage the client to dress more quickly 3Ask family members to dress the client 4Demonstrate methods on how to dress more quickly: 1 81.A pregnant client asks the nurse about the scheduled blood test for al- pha-fetoprotein (AFP). The nurse's explanation should include which of these comments? 1"It tells us how far along your pregnancy is." 2"It can help identify potential neurological defects." 3"The results help determine if the baby is growing normally." 4"The placental exchange of oxygen is measured.": 2 82.A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization? 1Protection from harm to self and others 2Return to independent functioning 3Elimination of negative findings 4Reorientation to reality: 1 83.A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take? 1Drink small amounts of liquids frequently 2Eat the evening meal within two hours of going to sleep 3Sleep with head propped on several pillows 4Take a proton pump inhibitor either before or after eating: 3 84.A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)? 2Digoxin (Lanoxin) 3Nitroglycerine ointment 4Metoprolol tartrate (Toprol XL): 2 90.A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse? 1"Smoking will decrease the circulation to my leg" 2"Coughing and deep breathing are important for a few weeks." 3"I will put my right leg through a full range of motion." 4"I might feel a throbbing pain in my right leg.": 3 91.The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? 1The cast material should be dipped several times into warm water 2The cast should be uncovered until it dries 3The casted extremity should be placed on a supporting surface 4The wet cast should be handled with the palms of hands for 48 to 72 hours: 4 92.The client undergoes a gastrectomy. Several hours after surgery, the na- sogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? 1Reposition the tube 2Increase the amount of suction 3Gently irrigate the tube with sterile normal saline 4Notify the surgeon: 3 93.A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? 1Reassure the child that the surgery will go fine with no problems 2Provide privacy with encouragement to work through feelings 3Distract the child with a choice of activities to do while waiting for surgery 4Make arrangements for friends to visit as soon as possible: 2 94.A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? 1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus 2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 3Open the bottom of the pouch to allow the flatus to be expelled 4Assist the client to ambulate to reduce the flatus in the pouch: 3 95.A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? 1Manage postoperative pain 2Maintain fluid and electrolyte balance 3Control bladder spasms with PRN medication 4Ambulate the client within a few hours after surgery: 1 96.The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond? 1"What a beautiful baby! The baby's eyes are just like yours." 2"This is a common occurrence after birth. Let's talk about how to accept the baby." 3"You seem upset, tell me about how you are feeling"? 4"Many women have postpartum blues and need some time to love the baby."- : 3 97.The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? 1"Do your eyes appear bloodshot and is there any itching?" 2"Tell me about your prescription for digoxin. Are you still taking the medica- tion?" 3"Call back in a week and schedule an appointment if your symptoms don't improve." 4"Is there anyone else at home who has the same symptoms?": 2 98.A client is admitted to the mental health inpatient unit with a diagnosis of major wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. 104. A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care? 1Activity intolerance related to an imbalance of oxygen supply and demand 2Imbalanced nutrition related to poor appetite 3Risk for impaired skin integrity related to dependent edema 4Constipation related to reduced activity level: 1 105. The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred? 1Performance on written tests 2Completion of a mailed survey 3Responses to verbal questions 4Reported behavioral changes: 4 106. The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.): may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. 107. The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis? 1Turn, cough and breathe deeply 2Ambulate client within 12 hours 3Maintain adequate hydration 4Splint incision when moving or coughing: 1 108. A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care? 1Assist the parents to plan quiet play activities with the toddler at home 2Stress to the parents that they will need relief care givers 3Instruct the parents for them and the toddler to avoid contact with persons with infection 4Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class: 4 109. A client becomes acutely short of breath with an SpO2 (oxygen satura- tion) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client? 1Simple face mask 2Partial rebreather mask 3Venturi mask 4Non-rebreather mask: 4 110. A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? 1Cannot ride a bicycle 2Cannot catch a ball 3Cannot skip on alternate feet 4Cannot stand on one foot: 4 116. A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best? 1"None of the laboratory reports show that you have any physical disease." 2"Try to eat a little bit. Breakfast is the most important meal of the day." 3"I know you believe that you have an incurable disease." 4"What has your primary health care provider told you?": 3 117. The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? 1Achieve harmony 2Respect life in old age 3Maintain energy balance 4Restore yin and yang: 4 118. The nurse is reinforcing dietary instructions to the parents of a child di- agnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet? 1A gluten-free diet, avoiding foods that contain wheat, rye and barley 2Balanced, high calorie diet with extra fat, salt, protein and calcium 3Foods low in sodium, potassium and phosphorus 4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group: 2 119. The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents? 1Progressive failure to adapt to peer pressure 2Reunion wish or a fantasy of some sort 3Feelings of anger or hostility toward others 4Feelings of alienation or isolation from peers: 4 120. When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? 1Ask the family members to call you when they notice the spot getting larger 2Record the findings in the nurse's notes 3Outline the spot with a pen and note the time and date on the cast 4Report the finding to the registered nurse (RN) charge nurse: 3 121. The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development? 1Makes simple association of ideas 2Bases conclusions on abstract thinking I3nterprets events from own perspective 4Thinks logically to organize facts: 4 122. The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing? 1Open the airway and deliver two breaths followed by 30 compressions 2Provide continuous chest compressions until someone comes with the crash cart 3Provide a cycle of 30 compressions followed by two breaths 4Provide 15 compressions and then pause while someone delivers one "breath" using an ambu bag: 3 123. A nurse is discussing with a group of parents when they can begin teaching their preschool children about injury prevention. Which approach should the nurse reinforce? 1Discuss the consequences of not wearing protective devices 2Protect calcium level 4Metabolic alkalosis: 2 129. The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.): a false positive test and should be avoided for at least 3 days before the fecal occult blood test; Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. 130. A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse? 1Suggest to elevate the arm higher than heart level 2Ask if numbness is present in the fingers and if the client can move the fingers 3Have the client make an appointment with the surgeon for the next day 4Approve the application of a cool cloth to the fingers of the affected arm: 2 131. The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? 1Bruise behind one ear 2Blurred vision 3Nausea and vomiting 4Headache: 1 132. Diagnosed with heart failure, the client had an implantable cardiovert- er- defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort? 1Encouraging the client to sit upright in bed 2Confirming advanced directives and plans for resuscitation 3Deactivating the implantable cardioverter-defibrillator (ICD) 4Assisting the client to eat several small meals: 3 133. The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium 4Take after meals: 1 134. A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit? 1Plan another pregnancy as soon as possible 2Seek causes of the death for prevention purposes 3Focus on the other healthy children at home 4Discuss feelings with support persons and each other: 4 135. A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the moth- er would be incorrect and indicate a need for reinforcement of information? 1"The therapy can be discontinued when the spots disappear." 2"I will boil the nipples and pacifiers for 20 minutes." 3"Expressed breast milk should be used immediately or frozen." 4"Nystatin should be given four times a day after my baby eats.": 1 136. The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the 2Explain the importance of the medication to the client 3Contact the client's health care provider about the refusal 4Report the behavior to the charge nurse: 1 142. The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? 1Close all doors in the area. 2Find the fire extinguisher. 3Remove oxygen devices. 4Begin evacuating the clients.: 1 143. The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take? 1Give the medication orally and follow-up with the health care provider. 2Hold the medication and contact the health care provider. 3Administer the prescribed dose as ordered. 4Check with the pharmacist to verify the order.: 2 144. The nurse is providing care for a client who was recently diagnosed with end- stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.): "Have you thought about what you want done as your disease progresses?" "What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" 145. A newly licensed nurse is concerned about time management. Which ac- tion should be most effective in the initial development of a time management plan? 1Set daily goals with the establishment of priorities 2Complete each task before beginning another activity 3Ask for additional assistance when necessary to complete tasks 4Keep a time log for what was done during the hours worked: 4 146. A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider? 1"When I emptied my urine catheter drainage bag it looked like rusty-colored water." 2"I just didn't sleep well the last few nights. I keep having sad thoughts running through my mind." 3"I really don't want home-delivered meals any longer. I am just not hungry." 4"My neighbors just don't visit me anymore since I came home from the hospital.": 1 147. The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase? 1Selection of interventions that are measurable and achievable 2Achievement or status of progress related to prior goals 3Identification of any findings of physical and psychosocial stressors 4Establishment of goals to ensure continuity of care: 2 148. A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? 1Clinical specialty certification by an accredited organization 2Complete and accurate documentation of assessments and interventions 3Sworn statement that health care provider orders were followed 4Above-average performance reviews prepared by nurse manager: 2 149. The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? 1The client with asthma who is scheduled for a chest X-ray prior to discharge 2The client with peptic ulcer disease who has been vomiting most of the night 3The client with chronic kidney disease who completed peritoneal dialysis two hours ago 4The client with pancreatitis who reports pain at a level of eight out of 10: 2 150. The nurse hears a health care provider (HCP) loudly criticizing one of the nurse to offer information about advance directives. 3Advance directives are not appropriate for this client due to the client's age. 4Refer this issue to the client's health care provider.: 2 155. The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person? 1Physical therapist 2Pharmacist 3Physical therapist 4Occupational therapist: 4 Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. 156. A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? 1The psychiatrist will need to grant permission to discuss the client's medica- tions. 2All clients have a right to be informed about their prescribed medications 3A decision to reinforce or not reinforce information about medications should be made by the nurse alone. 4It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications.: 2 157. The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take? 1Report this request immediately to the nurse manager. 2Review the client's medication administration record (MAR) for past wastes. 3Ask the nurse's client if they witnessed the waste of the partial dose. 4Confront the nurse about suspected narcotics diversion.: 1 158. A client diagnosed with bipolar disorder has been referred to social ser- vices for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request? 1Go ahead and provide the information, since the client is ready for discharge. 2Inform the caller that this kind of information is never given over the tele- phone. 3Refer the social worker to the health care provider to obtain the requested information. 4Verify that the client's medical record includes the client's written consent to release information.: 4 159. During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse? 1"Health care decisions can be made based on the client's wishes." 2"Specific instructions are listed for specific diseases." 3"A designated family member can make all decisions." 4"Do not resuscitate (DNR) orders are automatic under these conditions.": 1 160. The client requests not to be interrupted before 10 am because it inter- feres with the client's time to meditate. What action shall the nurse take first? 1Document the client's request in the medical record. 2Meet with the client to formulate a mutually agreeable schedule. nausea and unusual discomfort in the upper back 2The client diagnosed with peripheral artery disease (PAD) who reports cramp-like pains in both calf muscles following physical therapy 3The client with a history of heart failure (HF) who reports going to the bathroom "too much" after taking a diuretic 4The client diagnosed with hypertension whose last recorded blood pressure (BP) was 180/90 after returning from the radiology department: 1 166. The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? 1A trauma victim with multiple lacerations requiring complex dressings 2An older adult client diagnosed with cystitis who has an indwelling urethral catheter 3A confused client whose family complains about the nursing care given after the client's surgery 4A client, admitted for a possible stroke, with unstable neurological findings: 2 167. A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client? 1Include a family member and direct comments to that person 2Talk to the interpreter in advance and leave the client and interpreter alone for discussion 3Speak directly to the interpreter while asking questions 4Face the client while asking questions as the interpreter translates the infor- mation: 4 168. The 4-year-old child is newly diagnosed with hepatitis A. Which instruc- tions should the nurse reinforce with the child's parents? 1Use gentle cleansers to protect jaundiced child's skin from breakdown. 2Child can return to daycare two days after starting antibiotic treatment. 3Keep child on bedrest for several weeks before gradually resuming activity. 4Wash hands thoroughly with soap and warm water after contact with the child.: 4 The hepatitis A virus spreads through contaminated food or water, as well as unsani- tary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. 169. A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately imple- mented the restraints? (Select all that apply.): To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client. 170. The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include? 1Empty the child's mouth of any poisonous substance still present. 2Give the child a glass of milk to drink to neutralize the poisonous substance. 3Induce vomiting if the child is suspected of swallowing something poiso- nous. 4Start treatment before calling the Poison Control Center: 1 171. The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first? 1Contact employee or occupational health services. 2Look up the policy and procedure on needlestick injury. 3Immediately wash hands vigorously with soap and warm water. 4Notify the nursing supervisor and complete an incident report.: 3 172. The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take?: Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. 179. A community health clinic nurse is interviewing a client who is experi- encing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.): frequency and amount used color of bowel movements bruising 180. The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention? 1Increasing physical exercise 2Smoking cessation 3Stress management 4Weight reduction: 2 181. The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? 1Schedule regular visits to monitor wound healing. 2Involve the client in making decisions. 3Evaluate the client's understanding of appropriate foot care. 4Arrange for referral to a diabetic educator.: 2 182. The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy? 1Viewing the fetus as a separate and unique being. 2Accepting the loss of physical intimacy. 3Resolving any fears related to giving birth. 4Accepting physical changes related to pregnancy.: 4 183. A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs? 1Identify community resources. 2Assist with meal planning. 3Evaluate the home for safety hazards. 4Identify the client's learning needs.: 4 184. During a well-baby visit, the nurse is evaluating developmental mile- stones for the 7-month-old child. Which of these developmental activities should the child be able to perform? 1Sits without support 2Uses pincer grasp 3Says several words 4Drinks from a cup: 1 The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months. 185. A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? 1Ask the client to state his date of birth. 2Confirm that the client's hearing is intact. 3Observe the client while performing an activity. 4Ask the client to name the current U.S. president.: 2 191. A 20-year-old male client who has a profuse, purulent urethral discharge with painful urination is seen at a community health clinic. Which information will be most important for the nurse to obtain? 1Sexual orientation 2Recent sexual contacts 3Immunization history 4Contraceptive preference: 2 192. The nurse recognizes that which finding indicates a child has attained the developmental stage of concrete operations, according to Piaget? 1The child makes the moral judgment that "stealing is wrong." 2The child explores the environment with the use of sight and movement. 3The child thinks in mental images or word pictures. 4The child reasons that homework is time-consuming but necessary.: 1 193. After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse? 1"I will have to check on hospital regulations and policies." 2"These procedures have to be carried out by our staff." 3"Is there anything you need from me to perform the bath?" 4"A ritual bath will have to wait until after postmortem care.": 3 194. A nurse is working to establish a therapeutic relationship with a client. Which action would support the nurse's goal? 1Establish trust and rapport with the client. 2Identify with what the client is feeling. 3Praise the client for appropriate behavior. 4Advise the client on problem-solving techniques.: 1 195. The client diagnosed with paranoid-type schizophrenia is sitting alone, intently staring at and watching other clients and staff members. The client becomes hostile when approached with medication and claims that the med- ication controls the mind. What type of symptom(s) does the nurse recognize that this client is exhibiting? 1Antisocial behavior 2Negative symptoms 3Positive symptoms 4Inappropriate affect: 3 Symptoms of schizophrenia are commonly described as positive or negative. Posi- tive symptoms are behaviors and experiences present in a person with schizophre- nia that would not be present in a person without the illness. These are sometimes described as features that are "added" by the illness. In contrast, negative symptoms are those that reflect a decrease in normal functions, or abilities that have been "taken away." Positive symptoms of schizophrenia include delusions, hallucinations, hyper vigilance and disorganized thinking. 196. The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse notes that the client's wife is not visiting very often. When she does visit the client, she only stays for a brief time, stands in the corner and does not approach the client during interactions. Which of the grieving processes is the client's wife most likely experiencing? 1Disenfranchised grief 2Anticipatory grief 3Perceived loss 4Death anxiety: 2 anticipatory grief is the family member becomes distant and detached from the client and the client feels isolated and alone. Death anxiety is worry or fear related to dying that may be seen with a grieving child. Disenfranchised grief is when the individual cannot acknowledge the loss, perhaps because of an unrecognized loss, such as an abortion or a suicide. Perceived loss is a loss that cannot be verified by others such as a loss of self-esteem or a loss of control. 197. The nurse is caring for a postpartum Latina client who keeps declining the hospital food because it is "cold." What action should the nurse take initially? 1Send the food to be reheated. 4Early stage of alcohol withdrawal: 4 signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). 202. A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse? 1"Duloxetine is used to treat depression but can also be used to lower blood sugar levels." 2"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." 3"Duloxetine is not prescribed for either depression or diabetes." 4"Duloxetine is used to treat diabetes but can also be used to treat depres- sion.": 2 Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. 203. The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Select all that apply.): obstructive sleep apnea gallstones coronary artery disease breast cancer HYPERTHYROIDISM IS NOT ASSOCIATED WITH BEING OVERWEIGHT OR BMI 204. The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.): Prone to act impulsively Insecurity in relationships Craving and inability to abstain from alcohol 205. The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)? 1Chest pain, nausea, diaphoresis and tachycardia 2Nausea, vomiting, bloody stools and hypotension 3Headache, blurred vision, garbled speech and hypertension 4Excitability, disorientation, tremors and tachycardia: 4 206. A couple that recently immigrated to the United States tells the nurse about their concern that hospital staff is giving their child the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? 1Touch the child after or while looking at the child. 2Avoid touching or looking at the child. 3Look only at the parents and not the child. 4Instruct the parents to remain outside of the room.: 1 an "evil eye" is cast by looking at a person without touching them or while the person is unaware. The evil eye is believed to cause misfortune or injury. The spell is broken by touching the child while looking at them or assessing them. 207. The nurse is caring for a client diagnosed with end-stage heart failure (HF). The family members are distressed about the client's impending death. Which action should the nurse take initially? 1Explain the stages of death and dying to the family. Which response by the nurse would best help the client accept responsibility for their own behavior? 1"It was your choice to drink, so you need to take responsibility." 2"It is wrong for you to blame your problems on your family." 3"Yes, I can understand that families can be tough to deal with." 4"The lab report showed a high blood alcohol level when you were admitted."- : 4 213. A nurse is collecting data on a client believed to be in an abusive re- lationship. Which client statement is most indicative that this individual is experiencing intimate partner abuse? 1"I must have done something to deserve this." 2"No one else in my family has been treated like this." 3"I have only been in this relationship for two months." 4"I will keep praying that things will get better.": 1 214. A home health nurse is caring for a client diagnosed with late-stage, Lewy body dementia (LBD). The nurse is meeting with the client's family to discuss options for care of the client. What is the initial question the nurse should ask to assist the family with their decision-making process? 1"What is your opinion of nursing homes or assisted living facilities?" 2"Is your parent currently taking over-the-counter (OTC) or prescription med- ications?" 3"Are you able to assist with the care of your parent in any manner?" 4"What type of assistance does your parent require?": 4 215. The nurse is caring for a client with paraplegia due to a spinal cord injury at the T- 7 level. Which nursing intervention should be a priority for this client? 1Obtain a pressure- reducing mattress for the client's bed. 2Observe the client performing self-catheterization correctly. 3Consult with the discharge planner about equipment the client's needs at home. 4Encourage the client to increase intake of fluids and high-fiber foods.: 1 216. The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client? 1Enroll in a kickboxing class twice a week. 2Walk for 30 minutes, 3 to 5 times a week. 3Participate in swimming lessons three times a week. 4Go jogging 5 to 7 times a week.: 2 Teach the client (or reinforce teaching) that walking for 30 minutes, 3 to 5 times a week, is the single most effective exercise for osteoporosis prevention. 217. The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? 1A cup of cereal 2A slice of wheat bread 3A cup of yogurt 4An oatmeal cookie: 3 218. A client is on NPO status and has a nasogastric (NG) tube in place, con- nected to low-intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client? 1Allow the client to melt ice chips in their mouth. 2Provide oral care at least every 2 to 4 hours. 3Swab the client's mouth, using glycerin swabs. 4Provide the client mints to freshen their breath.: 2 219. The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective? 1Elastic, nontenting skin turgor 2Moist oral mucus membranes 3Urine output of 35 mL per hour 4No reports of diets are adequate if balanced with fruits and vegetables. 3Very low-calorie diets are intended for short-term use only. 4Very low-calorie diets are appropriate for long-term weight management.: 3 225. A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutri- tional information should the nurse provide to the parents? 1Keep the child fasting, give them nothing to eat, and return the next day. 2Give the child only clear liquids and gelatin for 24 hours. 3Continue a regular diet and add electrolyte replacement drinks. 4Give the child bananas, apples, rice and toast as tolerated.: 3 226. The nurse is providing care to an older adult client diagnosed with bilater- al pneumonia. Which intervention should the nurse implement to best promote the client's comfort? 1Encourage visits from family and friends. 2Keep conversations short. 3Increase the client's oral fluid intake. 4Monitor vital signs frequently.: 2 227. An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action? 1Severe abdominal pain 2A bladder ultrasound value of 900 mL 3A heart rate of 110 bpm 4A blood pressure of 180/105: 2 228. The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider? 1Serum creatinine level of 2.8 mg/dL 2Blood glucose level of 146 mg/dL 3Serum potassium level of 5.0 mEq/L 4Serum hemoglobin level of 15.7 g/dL: 1 normal range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment. Therefore, the creatinine value is the most important result 229. The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their understanding of the required diet modifications. Which menu items selected by the client indicate to the nurse that the client understood the teaching? 1Cheeseburger and baked potato chips 2Grilled cheese sandwich with a glass of skim milk 3Leftover turkey on a sandwich and fresh pineapple 4Vegetable pizza and ice cream: 3 Clients with HF should adhere to a low-sodium diet to prevent fluid volume excess. A sodium- restricted diet should consist of less than 2 grams of sodium per day. (A regular diet should include 4 to 6 grams of sodium per day.) 230. The nurse receives an order to give a client iron by deep injection. What does the nurse understand about the reason for using this method of administration? 1Provides more even distribution of the drug 2Prevents the medication from tissue irritation 3Ensures that the entire dose of medication is given 4Enhances absorption of the medication: 2 Deep injection, or Z-track, is a special method of giving medications via the intra- muscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. 231. A client has been taking alprazolam for three days. For which expected effect of the medication should the nurse evaluate the client? more rapidly. 2Due to a decrease in gastric emptying, higher medication doses are pre- scribed. 3Due to a decrease in renal drug excretion, a greater risk for adverse medica- tion effects exist. 4Due to an increase in metabolism, medications are prescribed more frequent- ly.: 3 236. The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administra- tion? 1Use an oral syringe to administer the medication, alternating with a pacifier. 2Mix the liquid medication with a full bottle of formula. 3Give half the dose now and the remaining amount in an hour. 4Ask the health care provider (HCP) to switch the medication to an injection.: 1 237. A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg . The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round.: 3.4 238. The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication? 1"I can stop taking the medication at any time." 2"It is safe to take extra doses if my pain becomes worse." 3"The medication might cause me to have insomnia." 4"My doctor prescribed it for the pain in my legs.": 4 239. The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, "Give APAP every six hours as needed for pain." Which parts of the medication order should the nurse clarify before administering the medication?: route drug name dosage 240. The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? (Select all that apply.): Notify health care provider Complete an incident report Monitor the client for adverse effects Document the error in the medical record 241. A client recovering from hip replacement surgery is taking aceta- minophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? 1Diffuse rash 2Constipation 3Wheezing 4Hyperglycemia: 2 242. A client is prescribed trimethoprim/sulfamethoxazole for recurrent uri- nary tract infections. Which statement by the nurse about this medication is correct? 1"You can stop the medication after five days." 2"Be sure to take the medication with food." 3"Drink at least eight glasses of water a day." 4"It is safe to take with oral contraceptives.": 3 Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring. 243. The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management?