NCSBN NCLEX 408 QUESTIONS WITH COMPLETE VERIFIED SOLUTIONS LATEST UPDATED 2024/25, Exams of Nursing

Download NCSBN NCLEX 408 QUESTIONS WITH COMPLETE VERIFIED SOLUTIONS LATEST UPDATED 2024/25 and more Exams Nursing in PDF only on Docsity! NCSBN NCLEX 408 QUESTIONS WITH COMPLETE VERIFIED SOLUTIONS LATEST UPDATED 2024/25 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 - Correct answer4 Explore for further identification about the nature of the problem 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." - Correct answer3 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 - Correct answer1An open wound on the heel with minimal discomfort- 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 - Correct answer4. Beef, one-half cup of lima beans, glass of skim milk, three- fourths cup of strawberries - 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 3. Hepatitis 4. Rubeola - Correct answer1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping - Correct answer1. Prejudice- A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize? 1. Increased competition between health care insurers 2. Increase in health care spending that's growing faster than the economy 3. Increase in the population who have health insurance 4. Increase in spending for end-of-life treatment - Correct answer2 A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child? 1. Maintain hydration and encourage fluids 2. Implement droplet precautions 3. Monitor respiratory rate and oxygen saturation 4. Anti- infective therapy - Correct answer2 A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse? 1Complaints for the feeling of pulling on the urinary catheter 2Light, pink to clear urine 3Occasional suprapubic cramping 4Minimal drainage into the urinary collection bag - Correct answer4Minimal drainage into the urinary collection bag A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time? 1Risk for fluid volume deficit 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia - Correct answer1Diarrhea, dry mouth, weight loss, reduced libido A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds 3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds - Correct answer4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 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?" - Correct answer2 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 - Correct answer3 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 - Correct answer1Squeeze the trapezius muscle firmly - 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 - Correct answer4Provide more frequent feedings- 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." - Correct answer3 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 - Correct answer2 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 - Correct answer2 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 - Correct answer2 A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about? 1Perfumed soap 2Shellfish 3Balloons 4Mold - Correct answer3 A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action? 1Assist the woman to empty her bladder 2Monitor the pulse and blood pressure 3Call the registered nurse (RN) immediately 4Check lochia for color and amount - Correct answer1Assist the woman to empty her bladder - The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider? 1Diminish destructive behavior through peer pressure 2Plan strict schedules with defined expectations 3Punish inappropriate behavior as it occurs 4Achieve a client's therapeutic goals - Correct answer4Achieve a client's therapeutic goals - A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response? 1"That depends on what you tell me." 2"I must report everything to the treatment team." 3"All right, I promise." 4"I can't make such a promise." - Correct answer4"I can't make such a promise." - A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment? 1"I know I must avoid crowds." 2"I will report any bruises or bleeding." 3"I plan to use an electric razor for shaving." 4"I will keep all laboratory appointments." - Correct answer1"I know I must avoid crowds." - The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene? 1Validate the client's advance directive 2Participate with the compressions or breathing as requested by the first nurse 3Bring the code cart - 4Relieve the first nurse on the scene and continue single person CPR - Correct answer3 The nurse and client are discussing the client's progress toward understanding the client's behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship? 1Termination 2Working - 3Orientation 4Pre-interaction - Correct answer2 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? A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? 1Provide a well-balanced nutritional intake 2Promote healing and strengthen the immune system 3Spare protein catabolism to meet metabolic and healing needs 4 stimulate increased peristalsis and nutrient absorption - Correct answer3 A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment 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." - Correct answer2 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 deteriorates 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 - Correct answer1 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 - Correct answer1 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 - Correct answer4 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 - Correct answer2 During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. - Correct answerAn 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 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 2Number of children in the home 3Knowledge level of the parents 4Age of children in the home - Correct answer4 When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best? 1"About two weeks" 2"One month" 3"Immediately" 4"Several days" - Correct answer1 A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy? 1Ambulate the client within four hours after procedure 2Change the dressing when it becomes saturated 3Monitor vital signs using post-op protocols 4Maintain client on NPO status for 24 hours - Correct answer3 The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T- tube to be? 1Dark brown 2Green 3Yellowish-brown 4Orange - Correct answer3 A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) - Correct answerSerious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time? 1Prior to going to sleep at night 2After each fecal elimination 3At the same time each day 4When it is one-third to one-half full - Correct answer4 A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? 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." - Correct answer3 The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent? 1Restricted physical activity 2Separation from family 3Altered body image 4Unrelieved pain - Correct answer3 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 - Correct answer3 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 - Correct answer2 2Protect the ego and diminish anxiety 3Eliminate anxiety and apprehension 4Avoid conflict and unpleasant consequences - Correct answer2 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 - Correct answer1 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 - Correct answer1 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 - Correct answer1 A pregnant client asks the nurse about the scheduled blood test for alpha-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." - Correct answer2 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 - Correct answer1 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 - Correct answer3 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)? 1Lifts head from the prone position 2Rolls from abdomen to back 3Falls forward when sitting 4Responds to parents' voices - Correct answer3 A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)? 1Paresthesia and muscle cramping 2Mild dysphagia and hoarseness 3Headache and nausea 4Irritability and insomnia - Correct answer1 An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus? 1Muscle weakness 2Respiratory function 3Bladder control 4Peripheral sensation - Correct answer2 There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? 1Use another client's nitroglycerin paste until pharmacy sends a tube for this client 2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart 3Call the pharmacy to send up a tube of nitroglycerin paste 4Call the prescriber and ask to substitute a different formulation of nitroglycerin - Correct answer3 A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents? 1Report a persistent cough to the health care provider 2The child can return to school in four days 3Administer chewable medication for pain 4The child may gargle as necessary for discomfort - Correct answer1 An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider? 1Diltiazem (Cardizem) 2Digoxin (Lanoxin) 3Nitroglycerine ointment 4Metoprolol tartrate (Toprol XL) - Correct answer2 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." - Correct answer3 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 - Correct answer4 The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (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 - Correct answer3 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 - Correct answer2 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 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. 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 - Correct answer1 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 - Correct answer4 A client becomes acutely short of breath with an SpO2 (oxygen saturation) 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 - Correct answer4 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 - Correct answer4 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? 1"Hello. My name is Elaine Jones and I am your nurse for today." 2"Good morning. You're in the hospital. I am your nurse Elaine Jones." 3"How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." 4"Good morning. I am Elaine Jones, your nurse. Do you remember where you are?" - Correct answer2 A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? 1Double glove when in contact with feces or emesis 2Wash hands thoroughly before and after any client contact 3Wear gloves when disposing of contaminated linens 4Use gloves when in contact with body secretions - Correct answer2 A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? 1Turn the baby every two hours using the abduction stabilizer bar 2Check frequently for swelling in the baby's feet 3Gently rub the skin with a cotton swab to relieve itching 4Place favorite books and push-pull toys in the crib - Correct answer2 A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization? 1Localized tenderness at the injection site 2Tympanic temperature of 104 F (40 C) 3Some irritability and fussiness 4Swelling at the injection site - Correct answer2 A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) - Correct answerCorrect Response Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Assess the wound for presence of drainage or bruising on the head 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?" - Correct answer3 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 - Correct answer4 The nurse is reinforcing dietary instructions to the parents of a child diagnosed 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 - Correct answer2 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 - Correct answer4 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 - Correct answer3 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 - Correct answer4 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 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium 4Take after meals - Correct answer1 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 - Correct answer4 A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother 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." - Correct answer1 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 nurse take initially? 1Place the bed in the low position 2Instruct the client to remain in bed 3Place the call bell within reach 4Have the client empty the bladder - Correct answer4 The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes? 1Being a picky eater 2Weight gain 3Bedwetting 4Oily and acne-prone skin - Correct answer3 An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first? 1Review the client's pattern of weight gain over the past year 2Encourage her to talk about her self-image 3Give her several pamphlets on postpartum nutrition 4Ask the mother to record her diet for the next few weeks - Correct answer2 A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention? 1Dry mouth with frequent requests for water 2Abdominal gas pains that are severe and disappear suddenly 3 Increased use of accessory muscles of breathing 4Difficulty sleeping due to leg cramps - Correct answer3 Legionnaire's disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately. The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)? 1Record and report the client's intake and output. 2Inspect and report peripheral IV site status. 3Palpate for edema in the lower extremities. 4Evaluate understanding of prescribed medications. - Correct answer1 A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take? 1Discuss with the client to find out about the preferred herbal preparation 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 - Correct answer1 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. - Correct answer1 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. - Correct answer2 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.) - Correct answer"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?" A newly licensed nurse is concerned about time management. Which action 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 - Correct answer4 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." - Correct answer1 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 - Correct answer2 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 - Correct answer2 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 - Correct answer2 4"Do not resuscitate (DNR) orders are automatic under these conditions." - Correct answer1 The client requests not to be interrupted before 10 am because it interferes 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. 3Notify the dietary department about the client's request. 4Adjust administration times for prescribed medications. - Correct answer2 A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate? 1"Have the client lift and move the walker out to arm's length, then walk into the walker." 2"If the client becomes dizzy while walking, ask the client to stop and take 10 fast, deep breaths." 3"As you assist the client to the chair, let me know if the client uses the quad cane correctly." 4"Stand on the client's strong side when you assist the client to the bathroom." - Correct answer1 The person assisting the client to ambulate should walk on the client's weak side, NOT STRONG, side. The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting? 1Perform actions based on reactive problem solving. 2Create a flow chart of department or staff interactions. 3Conduct chart audits for common error discovery. 4Improve the quality of care in a proactive manner. - Correct answer4 The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? 1Check sensation in the extremities 2Observe for mental status changes every four hours 3Reinforce findings of hypoglycemia when the client asks 4Measure blood pressure, pulse and respirations - Correct answer4 When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? 1"I'll come back and make the bed after I go to the lab." 2"If we work together we can get all of the client care completed." 3"Since I am late for lunch, would you perform my client's blood glucose test?" 4"This client seems confused, we need to watch the client closely." - Correct answer3 The nurse has been assigned to four clients. Which client should the nurse see first? 1The client with a history of coronary artery disease (CAD) reporting dyspnea, 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 - Correct answer1 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 - Correct answer2 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 information - Correct answer4 The 4-year-old child is newly diagnosed with hepatitis A. Which instructions 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. - Correct answer4 The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? (Select all that apply.) - Correct answerTo 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. 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 poisonous. 4Start treatment before calling the Poison Control Center - Correct answer1 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. - Correct answer3 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? - Correct answerMark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? - Correct answer"Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce? 1No solid food may be eaten for six hours after ingestion. 2Urine and saliva will be radioactive for 24 hours after ingestion. 3Wash laundry separately and rinse twice in hot water. 4Wait for 48 hours to have grandchildren visit at home. - Correct answer2 The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is: 1To ensure that treatment compliance will be monitored 2To trace and screen recent contacts the client had 4Percuss the area. - Correct answer2 A client has a family history of coronary artery disease (CAD). Which of the following findings should be of concern to the nurse? 1Low density lipoprotein (LDL) cholesterol level of 80 mg/dL 2Blood pressure of 154/78 3Serum creatinine of 0.4 mg/dL 4A glycosylated hemoglobin (Hb A1C) level of 4.8% - Correct answer2 Which of the following actions performed by the nurse indicates that additional education on ergonomic principles is needed to reduce the risk of injury? 1Flex the knees and knee close to an object, before lifting it from the floor. 2Use arm and leg strength to assist in repositioning a client in bed. 3Push a bed down the hall, instead of pulling it during transport. 4Bend and twist at the waist when assisting a client in transferring to the chair. - Correct answer4 A client with a back injury asks the nurse how chiropractic manipulation works. What is the nurse's best response? 1Electrical energy fields 2Spinal column manipulation 3Mind-body balance 4Exercise of joints - Correct answer2 The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and a significant family history of coronary artery disease. Which of the following prescriptions by the health care provider would treat a major modifiable risk factor of coronary artery disease? 1Atorvastatin 2Prednisone 3Albuterol 4Fluticasone/salmeterol - Correct answer1 Atorvastatin is an HMG-CoA reductase inhibitor, more widely known as a statin, and it is a medication used to treat hyperlipidemia. Statins reduce LDL levels, reduce triglycerides and increase HDL levels. Hyperlipidemia is a major modifiable risk factor of coronary artery disease. 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 - Correct answer2 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. - Correct answer1 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." - Correct answer3 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. - Correct answer1 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 medication 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 - Correct answer3 Symptoms of schizophrenia are commonly described as positive or negative. Positive symptoms are behaviors and experiences present in a person with schizophrenia 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. 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 - Correct answer2 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. 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. 2Encourage the client to eat for strength. 3Ask the client what foods are acceptable. 4Consult with the dietitian as soon as possible. - Correct answer3 An adolescent client is paralyzed from the waist down after being involved in a motor vehicle accident. Which client statement would indicate to the nurse that the client is using repression as an ego defense mechanism? 1"It's all the other driver's fault! They were driving too fast." 2"I don't remember anything about what happened to me." 3"My parents are heartbroken about my situation." 4"I know that I will walk again one day." - Correct answer2 Repression is the unconscious and involuntary forgetting of painful events, ideas and conflicts. The nurse is working with a couple who is experiencing intense anxiety after their home was completely destroyed by a fire. The nurse should implement which initial intervention? 1Suggest finding an apartment with a sprinkler system. 2Explore the couple's feelings of grief and loss. 3Determine what community housing resources are available. 4Provide a brochure on relaxation and stress relief. - Correct answer3 The couple has experienced a crisis, i.e., sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs. The nurse is evaluating a client who is being physically abused by the client's domestic partner. The client states, "I need a little time away." Which is the most likely response from the partner for which the nurse should prepare the client? 1Fear of rejection, resulting in increased rage toward the client 2Relief over a separation as a way to have some personal time 3Acceptance and understanding that the relationship is in trouble 4A new commitment to seek counseling to assist with problems - Correct answer1 3A handshake allows the use of therapeutic touch while maintaining boundaries. 4A handshake will not be misinterpreted as an invitation to more sexual behavior. - Correct answer3 The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder (OCD). Which behavior should the nurse expect to see with this diagnosis? 1The client is seen washing her hands every 15 minutes. 2The client exhibits repetitive, involuntary movements. 3The client verbalizes suspicions about thefts on the unit. 4The client prefers to interact with female staff members. - Correct answer1 OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). The nurse is caring for a client who has an alcohol use disorder (AUD). The client states that the client's dysfunctional family caused the addiction. 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." - Correct answer4 A nurse is collecting data on a client believed to be in an abusive relationship. 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." - Correct answer1 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 medications?" 3"Are you able to assist with the care of your parent in any manner?" 4"What type of assistance does your parent require?" - Correct answer4 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. - Correct answer1 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. - Correct answer2 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. 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 - Correct answer3 A client is on NPO status and has a nasogastric (NG) tube in place, connected 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. - Correct answer2 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 thirst - Correct answer3 The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult. Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)? 1The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. 2The nurse calls the health care provider (HCP) to request the removal of the indwelling urinary catheter for a two days postoperative client. 3The nurse cleanses hands with soap and water for 60 seconds after caring for a client with Clostridium difficile (C. difficile) infection. 4The nurse wears a gown and gloves when providing perineal care to a client with Vancomycin-resistant Enterococci (VRE) infection. - Correct answer1 A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client? 1Instruct the client to tilt their head back while swallowing. 2Position the client in an upright position while they are eating. 3Assist the client to drink through a straw. 4Instruct the client to use sips of water to help wash down food. - Correct answer2 A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? 1Ask the client about pain. 2Orient the client to the unit. 3Review the postoperative orders. 4Take the client's vital signs. - Correct answer4 The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? - Correct answerBowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? 1Very low-calorie diets often have severe and irreversible side effects. 2Very low-calorie 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. - Correct answer3 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 nutritional 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. - Correct answer3 3Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist. 4Due to an increase in metabolism, medications are prescribed more frequently. - Correct answer3 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 administration? 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. - Correct answer1 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. - Correct answer3.4 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." - Correct answer4 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? - Correct answerroute drug name dosage 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.) - Correct answerNotify health care provider Complete an incident report Monitor the client for adverse effects Document the error in the medical record A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? 1Diffuse rash 2Constipation 3Wheezing 4Hyperglycemia - Correct answer2 A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary 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." - Correct answer3 Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring. 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? 1Relief of pain will be achieved quickly. 2Pain therapy is based on the client's report of pain. 3High doses of opioid analgesics will be required. 4The client will most likely become addicted. - Correct answer2 The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client? 1"Notify your health care provider if your stools appear tarry or black." 2"You should massage the injection site for better absorption." 3"An intravenous (IV) catheter will be placed to administer the medication." 4"You must have your partial thromboplastin time (PTT) checked weekly." - Correct answer1 As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP A client who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client? 1Decreased urine output 2Facial flushing 3Cyanosis of the lips 4Increased pain in fingers - Correct answer2 Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud's disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur. A postoperative client has a prescription for acetaminophen with codeine for pain relief. The nurse understands which action to be the primary purpose of this drug combination? 1Faster onset of action 2Minimized side effects 3Enhanced pain relief 4Prevents tolerance - Correct answer A client diagnosed with tuberculosis is prescribed rifampin and isoniazid. Which information should the nurse include when reinforcing information about these medications? 1"You may have occasional problems sleeping." 2"You can take the medication with food." 3"You may notice an orange-red color to your urine." 4"You may experience an increase in appetite." - Correct answer3 The nurse is reinforcing medication interactions with a client who is taking warfarin. Which over-the-counter (OTC) medication should the nurse remind the client to avoid? 1Naproxen 2Diphenhydramine 3Acetaminophen 4Pantoprazole - Correct answer1 Naproxen can prolong bleeding time and should therefore be avoided by clients who take anticoagulants. The nurse is preparing to administer an antibiotic intramuscularly (IM) to a 2-year-old child. The total volume of the injection is 2 mL. What is the best approach for the nurse to take when administering this medication? 1Call the provider and request a smaller dose. 2Split the medication into two separate injections. 3Substitute an oral form of the medication. 4Inject the medication in the deltoid muscle. - Correct answer2 The nurse is reinforcing teaching for a client with chronic kidney disease about the prescribed aluminum hydroxide. Which is the best statement by the nurse about this medication? 1"It reduces potassium levels." 2"It increases urine output." 3"It controls stomach acid secretions." 4"It decreases phosphate levels." - Correct answer4 Phosphates tend to accumulate in the client with chronic kidney disease due to decreased filtration capacity of the kidneys. Antacids that contain aluminum such as aluminum hydroxide (Amphojel) are commonly used to lower phosphate levels. 2The medication will decrease the client's heart rate. 3The medication should be taken in the morning. 4The medication must be stored in a dark container. - Correct answer3 A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. Levothyroxine will cause an increase in the client's energy level and heart rate. A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next? 1Prepare for endotracheal intubation. 2Administer supplemental oxygen. 3Begin cardiopulmonary resuscitation. 4Prepare to administer naloxone. - Correct answer4 A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) - Correct answerAlendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time. The nurse observes a new nurse administering a rectal suppository to a client. Which actions are appropriate for the new nurse to implement? (Select all that apply.) - Correct answerThe nurse pushes the suppository in, up to the second knuckle. The nurse applies water-soluble lubricant to the suppository. The nurse places the client on the left side during insertion. After 10 minutes, the nurse turns the client to the right side. A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect? 1Level of consciousness (LOC) 2Amount of intravenous fluid infused 3Pulse and blood pressure 4Injuries to the extremities - Correct answer1 The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure? 1Time of the client's last meal 2History of allergies 3Amount of urine output 4BUN and creatinine level - Correct answer2 An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client? 1Encourage client to ambulate frequently. 2Spray the oropharynx with saline. 3Administer a nebulizer treatment. 4Push fluids for the next eight hours. - Correct answer3 A client is receiving heparin and warfarin after total hip replacement surgery. Lab results show an international normalized ratio (INR) of 5.5. Which priority action should the nurse take? 1Hold the next dose of warfarin. 2Monitor for bruising or bleeding. 3Notify the health care provider (HCP). 4Administer protamine sulfate. - Correct answer3 The therapeutic range for INR is 2 to 3, therefore a client with a 5.5 INR is at a high risk for bleeding and the nurse should notify the HCP immediately. A nurse is caring for a 2-year-old child who underwent a tonsillectomy at 8:00 am. At 11:00 am, the child has a temperature of 98.2 F (36.7 C). At 1:00 pm, the child's ⁰ ⁰ parent reports to the nurse that the child feels very warm to touch. What should the nurse do first? 1Reassure the parent that this is normal. 2Take the child's temperature. 3Offer the child cold oral fluids. 4Administer prescribed acetaminophen. - Correct answer2 The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which factor in the client's history indicates that the client is at an increased risk for deep vein thrombosis (DVT) in the postoperative period? 1Past hypersensitivity to heparin 2Family history of uterine cancer 3Estrogen replacement therapy for the past three years 4History of acute hepatitis A - Correct answer3 The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for development of a DVT. The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.) - Correct answerKinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the ventilator, creating high pressure in the ventilator circuit and setting off the high-pressure alarm. The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.) - Correct answerDrugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen (Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors that may cause a false positive result include bleeding gums following a dental procedure and the ingestion of red meats within three days before testing because red meats contain animal hemoglobin. A client is scheduled for a computerized tomography (CT) scan of the abdomen with contrast. What action should the nurse take before sending the client to the imaging department? 1Insert a temporary urinary catheter. 2Confirm that a signed consent is in the chart. 3Keep the client on bedrest. 4Hold all of the client's medications. - Correct answer2 An 80-year-old client with type 2 diabetes mellitus is admitted to the emergency department with worsening confusion and decreased level of consciousness. Which of these findings is most important for the nurse to report to the health care provider? 1Blood glucose of 380 mg/dL 2Arterial blood pH of 7.36 3Urine output greater than 100 mL/hour 4Serum osmolarity of 355 mOsm/L - Correct answer4 The nurse is monitoring a 45-year-old client who just underwent a cardioversion for dysrhythmias. The client's respirations are 12 per minute. Which action should the nurse take next? 1Measure the client's oxygen saturation. 2Ask another nurse to verify the respiratory rate. 3Notify the health care provider (HCP). 4Continue to monitor the client. - Correct answer4 Normal respirations range from 12 to 20 per minute; respirations of eight or less per minute would be a cause for concern. The nurse is preparing a client for an intravenous pyelogram (IVP) test. Which intervention should the nurse plan to implement? 1Limit client's fluid intake to 400 mL prior to the test. 2Inform client that no special preparation is necessary. 3Instruct client to maintain a regular diet until the test. 4Administer a laxative the evening before the test. - Correct answer4 It is important for the large intestine to be clear of stool to allow full visualization of the kidney, bladder and ureters. A client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.) - Correct answerOral abscess with tooth extraction History of aortic valve replacement Placement of an arteriovenous fistula for hemodialysis Placement of a central venous access device The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.) - Correct answerMother died of a myocardial infarction Low-density lipoprotein (LDL) level of 149 mg/dL History of diabetes mellitus Used to smoke 40 packs per year until one year ago The target LDL level for a client is less than 100 mg/dL. The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving? 1The client has normoactive bowel sounds. 2The client voided 300 mL of urine in the past two hours. 3The client denies any nausea or vomiting. 4The client reports the passing of flatus. - Correct answer2 A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care? 1Maintain the client on bedrest. 2Administer a stool softener daily. 3Implement seizure precautions. 4Discuss the client's wishes for organ donation. - Correct answer A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care? 1Maintain the client on bedrest. 2Administer a stool softener daily. 3Implement seizure precautions. 4Discuss the client's wishes for organ donation. - Correct answer2 To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing down when trying to defecate) and the risk for another syncopal episode, it is important to ensure that the client's bowel movements are soft and easily expelled. The client should also be instructed to avoid holding their breath or bearing down (Valsalva maneuver). A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally. Which instruction would be most appropriate for the nurse to give to the client regarding this medication? 1"You should use a straw when taking this medication." 2'Taking this medication will turn your urine dark orange in color." 3"Diarrhea is a common side effect when taking this medication." 4"You should take the medication with food to enhance absorption." - Correct answer1 Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw The nurse is caring for a client with severe iron deficiency anemia. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - Correct answerInstruct assistive personnel to allow the client to rest during care activities. Monitor the client for palpitations and orthostatic hypotension. Review the client's medical record for NSAID use. Encourage the client to eat more green leafy vegetables and beans. Monitor the client's stool for color, consistency and frequency. The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive person reports to the nurse that the client's last set of vital signs were blood pressure of 84/40 mm Hg, respiratory rate of 28 breaths/minute, heart rate of 112 and the client seemed short of breath. The nurse examines the client and also notes the presence of jugular vein distention. What should the nurse do next? 1Administer the prescribed metoprolol. 2Notify the health care provider. 3Place the client on nothing by mouth status. 4Obtain a 12-lead electrocardiogram. - Correct answer2 risk for cardiac tamponade due to jugular vein distention The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed with Raynaud's disease. What information from the client's health history would support this diagnosis? (Select all that apply.) - Correct answerThe client works in an office setting as a typist. The client smokes two packs of cigarettes per day. Warfarin is listed on the medication reconciliation form. The client complains of brittle fingernails that break easily. Fingers become cyanotic when exposed to cold objects. A client is admitted to the cardiology unit for treatment for recurrent supraventricular tachycardia. Which observation by the nurse would best indicate that the client's condition can be considered hemodynamically stable? 1The client denies any chest pain and capillary refill is less than three seconds. 2The client's blood pressure is 88/40 mm Hg. 3The client's pulse oximeter reads 91% on three liters nasal cannula. 4The client's cardiac monitor shows a heart rate of 170 beats per minute. - Correct answer1 A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first? 1Assess the client's deep tendon reflexes. 2Order the client a meal with foods high in magnesium. 3Obtain the client's heart rate and oxygen saturation. 4Place the client on fall risk and seizure precautions. - Correct answer3 The nurse administered furosemide to a client with acute pulmonary edema. Which observation by the nurse would indicate that the client is experiencing an adverse side effect of the medication? 1The client exhibits exertional dyspnea with walking. 2The client reports muscle cramps in both legs. 3The client's blood pressure is 104/60 mm Hg. 4The client's weight decreased by 2 lbs. in two days. - Correct answer2 Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia, an adverse drug effect of furosemide because this is a potassium wasting diuretic The nurse is reviewing the plan of care for a client with peripheral artery disease who has a history of leg pain with walking. Which interventions should the nurse include in the client's plan of care? (Select all that apply). - Correct answerEnroll the client in an exercise program that involves low-impact activities. Assist the client in selecting food items that are low in saturated fats and cholesterol. Reinforce teaching on the importance of not walking without shoes on. Assist the client in enrolling in a smoking cessation program. The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client? 1Meperidine 2Ibuprofen 3Acetaminophen 4Hydromorphone - Correct answer4 The nurse is planning care for a client newly diagnosed with essential hypertension. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - Correct answerEncourage the client to take daily, 30-minute walks. Explain the negative effects of hypertension on smoking. Other risk factors include genetics, asthma and exposure to occupational chemicals and air pollution. ALL HISTORY OF The nurse in the pediatric clinic is caring for an acutely ill, 10-year-old child. Which assessment finding would require immediate intervention by the nurse? 1Slow, irregular respirations 2Temperature of 101.3° F (38.5° C) 3Rapid, bounding pulse 4Profuse diaphoresis - Correct answer1 The nurse is preparing a client for a pulmonary CT angiogram with contrast to rule out a pulmonary embolism. For which laboratory result should the nurse notify the health care provider immediately? 1D-dimer level of 1.2 mcg/mL 2Serum creatinine level of 2.8 mg/dL 3Arterial blood gas PaO2 level of 80 mm Hg 4Serum troponin level of 0.1 mg/mL - Correct answer2 The client's creatinine level is significantly elevated (normal creatinine level is 0.8 to 1.2 mg/dL), placing the client at risk for dye-induced renal failure and the nurse should notify the health care provider of this lab result immediately. The nurse in the primary health care provider's office is reviewing the medical record of a client with idiopathic pulmonary arterial hypertension. The nurse should expect which potential clinical manifestations with this disease? (Select all that apply.) - Correct answerClassic symptoms include: exertional dyspnea and chest pain, fatigue, right- sided heart failure (cor pulmonale) due to the increased workload of the right ventricle and abnormal heart sounds, such as an S3. The home health nurse is reviewing the medical record of a client with closed-angle glaucoma in both eyes. Which statement by the client would support this diagnosis? 1"I have specks floating in my eyes." 2"I have to turn my head to see around the room." 3"I can't see out of my left eye." 4"I have constant blurred vision." - Correct answer2 Which action should the nurse take before communicating with a client diagnosed with presbycusis? 1Check the client for cerumen impaction. 2Ask for permission to turn off the television. 3Request a medical translator. 4Wait until family members have left. - Correct answer2 The nurse is planning care for a client diagnosed with Guillain-Barré syndrome. Which problem should the nurse identify as a priority? 1Difficulty breathing 2Altered bowel elimination 3Partial or total immobility 4Nutritional deficits - Correct answer1 The nurse is providing care to an 80-year-old client with the diagnosis of advanced Parkinson's disease. The nurse should know that the greatest risk to the client is related to which finding? 1Difficulties with reading and seeing at night 2Extreme weakness in the lower extremities 3Drooling and coughing when eating 4Dizziness and syncopal episodes - Correct answer3 The home health nurse is reviewing the plan of care for a client experiencing acute attacks of Ménière's disease. What is the priority intervention for this client? 1Instruct the client not to drive a motor vehicle. 2Provide assistance with bathing and dressing. 3Communicate clearly and use visual aids. 4Encourage bland foods and noncarbonated fluids. - Correct answer1 The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures and instructs the unlicensed assistive person (UAP) to prepare the client's room. Which piece of equipment should the UAP make sure to place in the room? 1Soft wrist restraints 2An oral airway 3A bedside commode 4Pads to be placed over the bed's side rails - Correct answer4 The nurse is reinforcing discharge instructions for a client after cataract surgery of the left eye. Which statements by the client indicate an understanding of the instructions? (Select all that apply.) - Correct answer"I will follow the instructions for the eye drops." "I will call the surgeon if the pain is intense." "I will not rub, press on or scratch my eye." The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré syndrome. Which intervention should the nurse plan for? 1Genetic testing of the client's children 2A bone marrow biopsy 3Administration of immunoglobulins 4Implementation of airborne precautions - Correct answer3 Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body's immune response. The nurse in the neurology office is reviewing information about levetiracetam with a 30- year-old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include? 1"You might experience irregular menses and intermittent bleeding." 2"Call the office immediately if you feel like hurting or killing yourself." 3"You should stay away from large crowds and sick children." 4"You should avoid becoming pregnant while taking this medication." - Correct answer2 Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations. The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of the following observations should be a priority for the nurse to address? 1Good lighting in the stairwell 2Throw rugs on the kitchen floor 3Lamps plugged directly into wall outlets 4Handrails in the bathtub - Correct answer2 The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take? 1Perform a focused neurological assessment. 2Administer acetaminophen for the headache. 3Alert the college's administration and dormitory staff. 4Obtain the client's immunization history. - Correct answer3 The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition? 1Takes an analgesic after performing household chores. 2Keeps the environment at a moderate temperature and free from drafts. 3Eats a bowl of hot, steaming soup every day for lunch. 4Performs vigorous brushing of teeth twice per day. - Correct answer2 Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack. The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.) - Correct answerSet-up a bladder training program for the client. The nurse at the outpatient surgery center is speaking with a client who is scheduled for a colonoscopy the next morning. Which information about the procedure should the nurse make sure to include? (Select all that apply.) "You will have an intravenous catheter inserted prior to the procedure." "You will be required to lay still for 6 to 8 hours after the procedure." "You should only consume clear liquids for the next 12 to 24 hours." "Remember to stop eating any food six hours before you come to the center." "Make sure to drink the entire bowel preparation liquid." - Correct answer"You will have an intravenous catheter inserted prior to the procedure." "You should only consume clear liquids for the next 12 to 24 hours." "Remember to stop eating any food six hours before you come to the center." "Make sure to drink the entire bowel preparation liquid." A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.) - Correct answerAdministration of pantoprazole Collection of a stool sample for occult blood testing Discontinuation of all NSAID medications The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed? 1"I will brush my teeth with a soft toothbrush to avoid bleeding gums." 2"I will eat enough protein and calories to stay healthy." 3"I will stop taking ibuprofen for my knee and back pain." 4"I will stop taking my lactulose when I have more than one loose stool." - Correct answer4 The nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.) - Correct answerThe most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals. The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.) Diminished pedal pulses Shortness of breath Increased weight gain Increased abdominal girth Elevated serum albumin level - Correct answerShortness of breath Increased weight gain Increased abdominal girth Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis? 1"Make sure to eat a low-fat, high-fiber diet." 2"Try to reduce smoking cigarettes to half a pack per day." 3"Limit alcohol intake to one drink a day." 4"Take the prescribed pancreatic enzymes on an empty stomach." - Correct answer1 The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client? 1Risk of infection of the surgical site 2Anxiety related to the cancer diagnosis 3Acute pain related to the surgery 4Impaired left arm circulation (lymphedema) - Correct answer3 The nurse is evaluating a client's understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.) Fresh apples Baked chicken Unsalted pretzels Slice of cheese Orange juice Baked potato - Correct answerFresh apples Baked chicken Unsalted pretzels A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese. A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first? 1Discuss the risk of infertility with the client. 2Collect a urethral swab from the client. 3Instruct the client to notify past sexual partners. 4Obtain information about the client's recent sexual encounters. - Correct answer4 The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.) Limit caffeinated and alcoholic beverages. Calculate accurate intake and output. Void every 1 to 2 hours to empty the bladder. Catheterize as needed for post-void residual urine. Monitor for bladder distention. - Correct answerlimit caffeine catheterize as needed monitor The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which findings would support this diagnosis? (Select all that apply.) Proteinuria Hypokalemia Elevated creatinine level Decreased glomerular filtration rate Hematuria Decreased blood area nitrogen - Correct answerproteinuria elevated creatinine decreased function hematuria A nurse is caring for a client with continuous bladder irrigation (CBI), following a transurethral resection of the prostate. Which finding would indicate the need for the nurse to increase the flow of the CBI? 1Bladder spasms 2Pain at the catheter insertion site 3Temperature of 99.8° F 4Blood clots in the catheter tubing - Correct answer4 A 68-year-old, postmenopausal, female client has been prescribed tamoxifen for breast cancer with bone metastases. The nurse should reinforce teaching about which potential adverse drug effect? 1Stroke-like symptoms 2Seizures Large fat pads on the back and shoulders History of pathologic fractures Tachycardia and panic attacks Changes in visual acuity Polyuria and polydipsia - Correct answerLarge fat pads on the back and shoulders History of pathologic fractures Cushing's disease occurs when there is an excess amount of cortisol. The nurse must understand that glucocorticoids, including cortisol, regulate metabolism and immune function, and play a role in the regulation and distribution of serum calcium levels. Therefore, deposition of fat pads on the back and shoulders, as well as fractures secondary to osteoporosis, are signs and symptoms of Cushing's disease that the nurse should be able to recognize. The nurse is caring for a client who was admitted for hyperglycemic hyperosmolar state (HHS). Which clinical finding would support this diagnosis? 1Blood sugar > 600 mg/dL 2Positive urine ketones 3Deep, rapid breathing pattern 4Serum pH level < 7.35 - Correct answer1 A client diagnosed with hypoparathyroidism would be most likely to display which of the following symptoms? 1Pruritus 2Flank pain 3Decreased reflexes 4Polydipsia - Correct answer1 The nurse is caring for a client with diabetes who was admitted for intractable vomiting. The nurse notes that the client's skin is cool to the touch, and the fingerstick blood sugar result is 55 mg/dL. What intervention should the nurse implement first? 1Administer glucagon. 2Recheck the blood sugar in 15 minutes. 3Offer the client a warm blanket. 4Administer an antiemetic. - Correct answer1 The nurse is reviewing the plan of care for a client with acute adrenocortical insufficiency. Which intervention should be a priority for this client? 1Administration of potassium supplements 2Electrocardiogram monitoring 3Implementation of a low-sodium diet 4Administration of insulin - Correct answer2 The nurse understands that the prescribed levothyroxine is effective when the client with hypothyroidism makes which statement? 1"I still feel lethargic and fatigued." 2"I have been having daily, formed bowel movements." 3"I have to change my sheets in the morning because I sweat a lot at night." 4"I was reprimanded at work after becoming angry with my boss." - Correct answer2 The nurse is caring for a client who presents with polyuria, polydipsia and a urine specific gravity of 1.002. The nurse suspects that the client is experiencing diabetes insipidus. Which risk factors would support this diagnosis? (Select all that apply.) Recent neurologic injury Current use of lithium History of recent surgery History of radiation treatment History of pulmonary disease - Correct answerRecent neurologic injury Current use of lithium History of recent surgery History of radiation treatment The nurse is planning care for a client admitted with uncontrolled hyperglycemia. Which activities can the nurse delegate to the unlicensed assistive person (UAP)? (Select all that apply.) Soak the client's feet in warm water prior to performing nail care. Administer insulin, but do not aspirate for blood prior to injecting. Report any skin lesions or breakdown to the nurse. Cut the client's toenails short and trim the corners with cuticle scissors. Apply moisturizing cream between the client's toes. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. - Correct answerReport any skin lesions or breakdown to the nurse. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. The nurse is caring for a client who has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions are appropriate for this client? (Select all that apply.) Monitoring of intake and output Administration of a loop diuretic Implementation of a fluid restriction Implementation of a low-sodium diet Administration of vasopressin - Correct answerMonitoring of intake and output Administration of a loop diuretic Implementation of a fluid restriction The nurse is caring for a client who has been diagnosed with Cushing syndrome. Which medication most likely contributed to this condition? Pantoprazole Prednisone Paroxetine Pravastatin - Correct answerprednisone The nurse is reviewing the medical record of a client with diabetes who was admitted for a surgical site infection. Which findings should the nurse report to the health care provider? (Select all that apply.) - Correct answerIn reviewing the lab values, the nurse should notify the HCP of the positive glucose in urine (normally, glucose is not seen in urine), A1C of 8% (desired range for a client with diabetes is 7% or less), and the serum glucose level of 220 mg/dL, which is higher than the normal range of 70 to 110 mg/dL. These abnormal lab results indicate that the client's diabetes is not managed well and most likely contributed to the client developing an infection. The nurse is reviewing the medical record of a client who has been diagnosed with osteoporosis. The nurse identifies which risk factors for this condition? (Select all that apply.) The client takes 10 mg of prednisone daily. The client performs weight-bearing exercises six days a week. The client weighs 200 lbs. (90.7 kg) with a height of 5 feet 2 inches (157 cm). The client is a 75-year-old Caucasian female. The client has a 30 pack per year smoking history. - Correct answerOsteoporosis is the loss of bone density that leads to weakness of the bone. Risk factors for osteoporosis include being a postmenopausal woman (lack of estrogen), smoking, thin stature, steroid use, lack of weight-bearing exercise, such as prolonged immobility or a sedentary lifestyle, and ethnicity. prednison 75 30pack The nurse in the outpatient clinic is following up on a client with a fractured arm. The client's arm was placed in a cast four hours ago. The client states, "my fingers are tingling and feel cold." Which action should the nurse take first? 1Apply an ice pack to the cast to reduce swelling. 2Elevate the client's arm above the level of the heart. 3Check the capillary refill in the client's fingers. 4Notify the health care provider. - Correct answer3 A client has received instructions for the management of osteoarthritis. Which statement by the client would indicate a need for additional teaching? 1"Early surgical intervention is the preferred treatment." 2"Gradual weight loss may help my pain." 3"It is important for me to balance my exercise and rest periods." 4"I will avoid driving after I have taken cyclobenzaprine." - Correct answer1 The nurse is reviewing the medical record of a client who has been diagnosed with systemic lupus erythematous (SLE). The nurse would expect which findings associated with this disease? (Select all that apply.) Generalized weakness 3Encourage the client to increase their intake of vitamin D. 4Administer the alendronate 30 to 60 minutes before the client eats. - Correct answer1 The office nurse is discussing how to prevent an acute gouty attack with a client who has gout. Which actions should the nurse recommend to the client? (Select all that apply.) Limit their intake of shellfish and red meats. Take the prescribed prednisone regularly. Limit their consumption of alcohol. Implement stress reduction techniques. - Correct answerlimit shellfish/meat intake limit consumption of alcohol stress reduction techniques The nurse observes an unlicensed assistive person (UAP) providing care to a client who had a total hip arthroplasty 24 hours ago. Which action by the UAP would require the nurse to intervene immediately? 1Placing non-slip foot wear on the client prior to ambulation. 2Placing a raised toilet seat in the client's bathroom. 3Standing by the client's non-operative side during ambulation. 4Reminding the client not to cross their legs. - Correct answer3 When assisting the client during ambulation following a total hip arthroplasty, the UAP should stand on the operative side (i.e., the side of the surgery) to help provide support to the client because that is the client's weaker side. The home health care nurse is caring for a client who has epilepsy. While the nurse is providing care, the client has a seizure. Which intervention would be most appropriate to prevent an injury to the client? 1Loosening clothing around the waist 2Asking the client to state where they are 3Lowering the client to the ground 4Placing a pillow under the client's head - Correct answer3 The nurse is participating in a disaster simulation that involves a school bus accident. The nurse is assigned to care for the following four clients in a rural hospital's emergency department. Which client should the nurse see first? 1The client with a penetrating abdominal wound 2The client with multiple facial abrasions 3The client with an open humerus fracture 4The client with a third degree burn to the arm - Correct answer1 A client with a known large abdominal aortic aneurysm develops a sudden change in level of consciousness and tachycardia. The client's blood pressure is 72/48. What should the nurse do first? 1Activate the hospital's emergency response team. 2Page the client's health care provider. 3Conduct a complete head-to-toe physical assessment. 4Obtain a 12-lead electrocardiogram. - Correct answer1 The nurse is caring for a client with a medical history of peripheral artery disease, hypertension and smoking. The client reports severe pain in the right lower leg that started very suddenly and did not get better after receiving an analgesic. What action should the nurse take first? 1Check the client's pedal pulse. 2Offer the client an ice pack for the pain. 3Administer an additional dose of the analgesic. 4Notify the health care provider. - Correct answer1 A client presents to the emergency department with a prolonged asthma attack that did not resolve after the client used a metered-dosed inhaler at home. Which medication should the nurse plan to administer first for this client? 1Oral prednisone 2Fluticasone inhaler 3Intravenous azithromycin 4Nebulized albuterol - Correct answer4 The nurse on a postpartum nursing unit is receiving report about a client who had a normal spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots on her peri-pad for the last few hours. The client's most recent blood pressure is 88/56, and her heart rate is 118. The nurse enters the client's room and notices blood oozing from her intravenous insertion site. Which action should the nurse take first? 1Notify the client's health care provider. 2Palpate and massage the client's uterus. 3Perform peri-care and change the client's peri-pad. 4Encourage breastfeeding to promote uterine contractions. - Correct answer1 The nurse is beginning a shift caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first? 1A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64 2A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home 3A client admitted with hepatic encephalopathy who has an elevated ammonia level 4A client admitted with a transient ischemic attack, who has a bubble study echocardiogram ordered - Correct answer2 The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first? 1A client diagnosed with heart failure who has a SpO2 of 82%. 2A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88. 3A client diagnosed with infective endocarditis who has a temperature of 101.8 °F (39° C). 4A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute. - Correct answer1 The off-duty nurse witnesses a motor vehicle accident and is concerned that the driver of the automobile may be injured. What should the nurse do first? 1Consider scene safety to prevent further injury. 2Check the driver's respiratory rate. 3Check the driver's pulse. 4Minimize movement of the driver's cervical spine. - Correct answer1 The nurse is talking with a client during a home health visit. The client states, "my right arm and right leg are beginning to feel heavy." The nurse notices the client is having trouble speaking and has stopped moving the right side of their face. What action the nurse should take first? 1Take the client's vital signs. 2Document the onset of symptoms in the medical record. 3Call 911. 4Ask the client if they have a headache. - Correct answer3 An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first? 1Obtain a STAT 12-lead electrocardiogram. 2Obtain a STAT electroencephalogram. 3Administer levetiracetam intravenously. 4Administer lorazepam intravenously. - Correct answer4 The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first? 1Echocardiogram 2Computerized tomography scan 3Arterial blood gas 4Chest X-ray - Correct answer2 The off-duty nurse is helping to administer first aid following a mass casualty incident in the community. Emergency medical personnel at the scene have started to triage victims, using a common, color-tagging system. Which tag color usually indicates the highest priority for a victim to receive care? 1Green 2Red 3Yellow 4Black - Correct answer2 The nurse in a long-term care facility is reviewing the medical record of a newly admitted client. Which of the following factors put the client at an increased risk for developing a pressure ulcer? (Select all that apply.) The client has a history of exercise-induced asthma. The client has diabetes mellitus. The client has a body mass index (BMI) of 30 The client is receiving an immunosuppressant drug for rheumatoid arthritis. The client is alert and oriented to person, place, time and situation. - Correct answerThe client has diabetes mellitus. Correct! The client has a body mass index (BMI) of 30. Correct! The client is receiving an immunosuppressant drug for rheumatoid arthritis. The nurse in a long-term care facility is observing the certified nursing assistant (CNA) change a soiled incontinence brief on a client with incontinence-associated dermatitis (IAD). Which actions by the CNA would require the nurse to intervene? 1Positions the client in a side-lying position. 2Places an absorbent dressing pad over the wound. 3Applies a thin layer of barrier cream to the perineum. 4Cleanses the perineal area with toilet tissue. - Correct answer4 The nurse in a long-term care facility is reviewing the plan of care for a client with quadriplegia. Which risk assessment scale should be included for this particular client? 1The Hamilton scale 2The Braden scale 3The Wong-Baker scale 4The Hendrich scale - Correct answer2 The Braden scale is used for predicting pressure ulcer risk, and should be included in this client's plan of care. The Hendrich scale is used for fall risk. The Wong-Baker scale uses visual faces to assess pain. The Hamilton scale is used to rate anxiety A client presents at an urgent care center after burning their hand while cooking. The client's burn wound has an intact skin surface, with redness and blistering that covers their posterior hand. How should the nurse describe this wound when documenting in the client's medical record? 1A superficial-thickness wound 2A partial-thickness wound 3A deep full-thickness wound 4A full-thickness-wound - Correct answer2 The wound described here is a partial-thickness wound. It involves the entire epidermis and varying depths of the dermis. These wounds are red, moist and blanch when pressure is applied. The nurse is caring for a client with a large wound. In order to promote healing. What is the most appropriate meal selection for this client? 1Turkey, spinach and orange juice 2Green salad, apple and ice cream 3Pasta, broccoli and fat free milk 4Chicken breast, potatoes and gelatin - Correct answer1 Protein, vitamins A and C and zinc promote wound healing and immune system functioning. A client has herpes simplex I with visible cold sores on the lips. Which intervention is most important for the client to implement to prevent spreading the infection? 1Take antiviral medication as prescribed. 2Wash hands frequently. 3Avoid sharing towels. 4Do not scratch the affected area. - Correct answer3