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121. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads C. Stepping with his affected leg first when going up stairs D. Moving both crutches with the stronger leg forward - CORRECT ANSWER- - A (Support body weight using both Crutches when shifting weight) (Unaffected First when going upstairs)
122. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot B. Kick a ball forward C. Climb Stairs with alternate feet D. Ride a tricycle - CORRECT ANSWER- - B

123. A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. Im sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. - CORRECT ANSWER- - D A nurse is assessing a client following a ischemic (hemorrhagic) stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures - CORRECT ANSWER- - C A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. B. Check the client's serum albumin levels C. Examine for leakage at the site of the procedure D. Confirm that the client is able to urinate - CORRECT ANSWER- - A

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with this leg extended. B. Maintain eye contact with the newborn during feedings. C. Minimize noise in the newborn environment D. Administer naloxone to the newborn - CORRECT ANSWER- - C ● Reduce environmental stimuli (decrease lights, lower noise level). treat with Currently, the most common first-line medications used to treat NAS include morphine, methadone, and buprenorphine A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? A. Participate in community drills and mock events. B. Vaccinate susceptible children and adults against smallpox C. Assess types, levels and scopes of disasters. D. Make quarantine preparations for those exposed to anthrax - CORRECT ANSWER- - C - Assess first A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect? A. Ritualistic behavior B. Exhibits separation anxiety C. Preoccupied with aging D. Suspicious of others. - CORRECT ANSWER- - C

A = OCD

B = Dependent D = Paranoid A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Withdraw the client's TV privileges if he does not attend group therapy B. Place the client in seclusion when exhibits signs of anxiety C. Encourage the client to take frequent rest periods. D. Encourage the client to spend time in the day room - CORRECT ANSWER- - C A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. - CORRECT ANSWER- - A (Stage IV Kidney Disease) A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area

c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area - CORRECT ANSWER- - B A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet - CORRECT ANSWER- - C People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum, strawberry, tomato A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Seizure disorder b. Polycystic ovary syndrome c. Renal insufficiency d. Gluten intolerance - CORRECT ANSWER- - C A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Contractions

b. Vomiting c. Hypertension d. Epigastric pain - CORRECT ANSWER- - A A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? a. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site b. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120 c. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate d. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing - CORRECT ANSWER- - D. ** Bleeding A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after i first feel the urge to urinate d. I will determine which muscles to contract by starting and stopping my urine stream - CORRECT ANSWER- - D A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? a. I need to have an enema before the test b. I should urinate before the test

c. I will lie on my left side during the test d. I will drink an oral glucose solution during the test - CORRECT ANSWER- - B A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect? a. Memory loss b. Slurred speech c. Elevated temperature d. hypotension - CORRECT ANSWER- - C Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules - CORRECT ANSWER- - B A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Increase intake of foods high in gluten b. Consume food high in bran fiber c. Sweeten foods with fructose corn syrup d. Increase intake of milk product - CORRECT ANSWER- - B Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client's condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client's condition. - CORRECT ANSWER- - B A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client b. Change client's position every 2 hours c. Perform range-of-motion exercises to client's extremities. d. Place the clients right hand in supination position. - CORRECT ANSWER- - A. (ABCs) A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will decrease my protein intake during the third trimester" b. "I will need to increase my insulin doses later in my pregnancy" c. "I will increase my carbs at breakfast and limit them the rest of the day" d. "I will decrease my calorie consumption during the first trimester" - CORRECT ANSWER-

• B

( increase protein for basic growth) (increase calorie) A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau's sign b. Assess the client's skin turgor c. Check the client's motor strength d. Measure the client's pupil size - CORRECT ANSWER- - A A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. "I should clean my stoma with warm water"( can use low ph soap and water) b. " My stoma should be bright pink or red"(pink, red and moist) c. "I should change the stoma pouch every day" d. "I should cut my pouch opening ⅛ inch larger than my stoma"(allow expansion) - CORRECT ANSWER- - C A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea c. Pruritus d. Polyuria - CORRECT ANSWER- - A

Other signs include ( bradypnea, less than 12/min) Pruritus( sign of allergic reaction) (oliguria, less than 30 ml/hr) A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. "Your desire to be an organ donor must be documented in writing" b. "I cannot be a witness for your consent to donate" c. "You must be at least 21 years of age to become an organ donor" d. "Your name cannot be removed once you are listed on the organ donor list - CORRECT ANSWER- - A A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake c. Provide the client with 4 g sodium diet d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr - CORRECT ANSWER- - A pt. should be on bedrest

A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen - CORRECT ANSWER- - B (not sterile use the port for culture and UA) A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension - CORRECT ANSWER- - A A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic - CORRECT ANSWER- - B

A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension - CORRECT ANSWER- - B

154. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure - CORRECT ANSWER- - A A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. - CORRECT ANSWER- - B

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. "You can add the medication to a half-cup of your child's favorite juice." B. "Repeat the dose if your child vomits within 1 hour after taking the medication." C. "Limit your child's potassium intake while she is taking this medication." D. "Have your child drink a small glass of water after swallowing the medication." - CORRECT ANSWER- - D A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension - CORRECT ANSWER- - A A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation treatment. C. A client who is 1 day postoperative following a vertebroplasty D. A client who is receiving heparin for deep vein thrombosis. - CORRECT ANSWER- - C & D

159. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl (WNL) B. WBC 9,800/mm (WNL) C. Creatinine 0.9 mg/dl (WNL) D. Potassium 5.2 mEq/L - CORRECT ANSWER- - D
160. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Engage the client in activities that increase sensory stimulation. B. Discourage physical activity during the day. C. Establish a toileting schedule for the client. D. Use clothing with buttons and zippers. - CORRECT ANSWER- - C A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations a. Orthostatic hypotension b. Dependant Edema c. Decreased Hematocrit d. Neck vein distention - CORRECT ANSWER- - A Dependant Edema- fluid volume excess Decreased Hematocrit - fluid volume excess d/t super diltion Neck vein distention - fluid volume excess

A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder? a. The client is overly concerned about minor details b. The client exhibits impulsive behavior c. The client is exceptionally clingy to others d. The client might act seductively - CORRECT ANSWER- - B - spending money or giving away money/possessions A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider? a. 3+ deep tendon reflexes b. Protruding hemorrhoids c. Urinary frequency d. Supine hypotension - CORRECT ANSWER- - A 3+ deep tendon reflexes - preeclampsia

• teach them side lying position A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first? a. Inform the provider of the time of the last does of pain medication b. Document the sequence of events as they occur c. Provide non pharmacological pain management interventions d. Instruct the client about the steps of the procedure - CORRECT ANSWER- - A

A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report? a. The client was intubated without complication b. The estimated blood loss was 250 ml c. There was a total of 10 sponges used during the procedure - what kind d. The client is a member of the board of directors - CORRECT ANSWER- - B A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? a. Left ventricular failure b. Cardiogenic shock c. Hypovolemia d. Hypotension - CORRECT ANSWER- - A A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range b. A client who has cancer with a sealed implant for radiation therapy - an implant is inside them, and its active c. A client who is 1 day postoperative following a vertebroplasty d. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for Hospital and that other Coumadin for home - CORRECT ANSWER- - C

A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? a. Fasting blood glucose 108 mg/ dl b. WBC 9,800 mm3 > 4,800 is normal c. Creatnine 0.9 mg/dl , < 1.0 is normal d. Potaissium 5.2 meq / L 3.5 - 5.0 = - CORRECT ANSWER- - D A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? a. Engage the client in activities that increase sensory stimulation. b. Discourage physical activity during the day c. Establish a toileting schedule for the client d. Use clothing with buttons and zippers - CORRECT ANSWER- - C A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred - CORRECT ANSWER- - C A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take?

a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured - CORRECT ANSWER- - C Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding b. Dissolve the medications together c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water - CORRECT ANSWER- - C

• Crush meds first before adding
• some meds can mix, others can't
• flush NG tube with 10ml The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor

c. Seductive Behavior d. Lack of remorse - CORRECT ANSWER- - C A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure c. The nurse will initiate acupuncture when I arrive at the unit d. I can use my ultrasound picture as a focal point during contractions - CORRECT ANSWER- - D

• biofeedback would be taught earlier to control other pain, not pain of labor
• TEE nerve stimulator - This would mess with the readings of the pt and baby
• No needles during labor A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute b. ST segment elevations c. 2 PVCs per minute d. Widened P wave - CORRECT ANSWER- - B = infarction A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?

a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Increases the tpn infusion rate each hour until the prescribed rate is achieved - CORRECT ANSWER- - C A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? a. Yield in situations of conflict to maintain group Harmony b. Share personal opinions to help influence the group's values c. Use modeling to help the clients improve their interpersonal skills d. Measure the accomplishments of the group against a previous group - CORRECT ANSWER- - C

• If conflict arises it is your responsibility to contain it
• your focus is having group share their personal thoughts and feelings to facilitate discussion
• no comparison A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations b. Multiply the number of respirations in 15 seconds by 4 c. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear

d. Count respirations for 1 minute if the rhythm is irregular - CORRECT ANSWER- - D A client's partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. review confidentiality policies with laboratory employees c. contact the laboratory manager regarding the situation d. Notify the facilities legal department - CORRECT ANSWER- - A

• would be the job of the Facility manager or someone who audits or teaches HIPAA stuff
• you are not high enough up the chain to do that
• no need to go that far A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client's medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infections d. Migraines with aura - CORRECT ANSWER- - D

Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache - CORRECT ANSWER-

• A A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure. b. Position the client over an overbed table prior to the procedure. c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hr prior to the procedure. - CORRECT ANSWER- - A A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia? a. Maternal hypoglycemia b. Chorioamnionitis c. Fetal anemia d. Maternal fever - CORRECT ANSWER- - A

A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic? a. "You should make sure your partner takes the prescribed medication." b. "Why do you think your partner's symptoms are progressing so quickly?" c. "You did the right thing by bringing your partner in for treatment." d. "Can you talk about what was happening with your partner at home?" - CORRECT ANSWER- - D A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver function test d. Serum creatinine - CORRECT ANSWER- - C A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels." b. "The PCA will deliver a double dose of medication when you push the button twice." c. "You should push the button before physical activity to allow maximum pain control." d. "You can adjust the amount of pain medication you receive by pushing on the keypad." - CORRECT ANSWER- - C

A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure. - CORRECT ANSWER- - D A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? a. "How long have you been hearing the voices?" b. "What are the voices telling you?" c. "Have you taken your medication today?" d. "I realize the voices are real to you, but I don't hear anything."- - CORRECT ANSWER- - B