Nursing Practice Questions: Comprehensive Predictor 2019, Exams of Nursing

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A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. - Correct answerA. Administer the feeding over 30 min.

2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D.Constipation for 2 days. - Correct answerB. Apical pulse 58/min A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family want the client to have life-sustaining measures. Which of the following action should the nurse take? A.Arrange for an ethics committee meeting to address the family's concerns. B. Support the family's decision and initiate life-sustaining measures. C. Complete an incident report. D.Encourage the family to contact an attorney. - Correct answerA. Arrange for an ethics committee meeting to address the family's concerns. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. - Correct answerA. Store the glasses in a labeled case. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client's room. B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. D. Wear a mask when changing the linens in the client's room. - Correct answerC. Wear gloves when providing care to the client.

A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. - Correct answerD. Obtain a cardiac rehabilitation consultation. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia - Correct answerB. Thrombophlebitis. A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client's understanding of life-sustaining measures. C. Determine the client's preferences about post mortem care. D. Request a conference with the client's family. - Correct answerB. Evaluate the client's understanding of life-sustaining measures. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing. - Correct answerA. Substernal retractions. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the .following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. Instruct the client to lie on his right side. - Correct answerB. Insert a large-bore NG tube. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse's priority? A. Psychologist. B. Social worker. C. Occupational therapist.

D. Speech-language pathologist. - Correct answerD. Speech-language pathologist. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. Erythrocyte sedimentation rate 75 mm/hr - Correct answerD. Erythrocyte sedimentation rate 75 mm/hr A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Pre-albumin. - Correct answerA. Platelet count. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. - Correct answerB. Palpate the pulse distal to the cast. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. - Correct answerA. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. D. Allow extra time for the client to perform tasks. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. - Correct answerB. CINAHL.

A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. - Correct answerD. Administer 100% humidified oxygen. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client's mouth when he is ready to eat. B. Provide total care in performing the client's ADLs. C. Maintain the client on bed rest. D. Place the client's left arm on a pillow while he is sitting. - Correct answerD. Place the client's left arm on a pillow while he is sitting. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client's situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. - Correct answerA. Confront the client about this behavior. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client's room. B. Limit the client's visitors to 30 min per day. C. Discard the client's linens in a double bag. D. Discard the radioactive source in a biohazard bag - Correct answerB. Limit the client's visitors to 30 min per day. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea - Correct answerA A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation.

C. Post term with oligohydramnios. D. Chorioamnionitis - Correct answerC. Post term with oligohydramnios. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. "What are the indications that my baby needs an IV?" Which of the following responses should the nurse make? A. "Your baby needs an IV because she is not producing any tears" B. "Your baby needs an IV because her fontanels are budging" C. "Your baby needs an IV because she is breathing slower than normal" D. "Your baby needs an IV because her heart rate is decreasing" - Correct answerA. "Your baby needs an IV because she is not producing any tears" A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be over hydrated" - Correct answerC. "Rise slowly when getting out of bed" A nurse is creating a plan of care for a newly admitted client who has obsessive- compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors. - Correct answerA. Allow the client enough time to perform rituals. A nurse is caring for a client who has depression and reports taking ST. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C.Pseudo parkinsonism. D. Acute dystonia. - Correct answerA. Serotonin syndrome A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse. - Correct answerB. Dyspnea.

A nurse is calculating a client's expected date of delivery. The client's last menstrual period began on April 12. Using Nagele's rule, what date should the nurse determine to be the client's expected delivery date? (Use mmdd format.) - Correct answer0119 date A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. - Correct answerB. The group encourages members to focus on a particular issue. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching. A. "OOB with assistance for breakfast" B. "Given 2 mg MSO4 IM for report of pain" C. "Dressing changed qd" D. "Administered 8 u regular insulin sq." - Correct answerD. "Administered 8 u regular insulin sq." A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Apply pressure to the lacrimal punctum.
2. Ask the child to look upward.
3. Pull the lower eyelid downward.
4. Instill the drops of medication.
5. Place the child in a sitting position. - Correct answer5. Place the child in a sitting position.
6. Ask the child to look upward.
7. Pull the lower eyelid downward.
8. Instill the drops of medication.
9. Apply pressure to the lacrimal punctum. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. - Correct answerD. Review the facility policy about the use of an interpreter. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? A. Urine output 20 ml/hr.

B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. D. Contractions every 5 min that last 30 seconds. - Correct answerB. Montevideo units constantly 300 mm Hg. A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs. D. Providing crisis intervention through a mobile counseling unit. - Correct answerA. Teaching parenting skills to expectant mothers and their partners. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client's blood type with the type and cross match specimens. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client's identification band matches the number on the blood unit. - Correct answerA. Match the client's blood type with the type and cross match specimens. A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. "I have been experiencing more tremors in my left arm than before" B. "I noticed that I am having a harder time holding on to my toothbrush" C. "Lately, I feel like my feet are freezing up, as they are stuck to the ground" D. "Sometimes, I feel I am making a chewing motion when I'm not eating" - Correct answerC. "Lately, I feel like my feet are freezing up, as they are stuck to the ground" A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. - Correct answerA. Increased creatine. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. "Did the doctor discuss with you that there was a change in this medication?" B. "I recommend that you take this medication as prescribed" C. "Do you know why this medication is being prescribed to you?" D. "I will call the pharmacist now to check on this medication" - Correct answerD. "I will call the pharmacist now to check on this medication"

A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. - Correct answerA. Use three pronged grounded plugs. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. - Correct answerD. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat". B. A client who has gout and states, "I can continue to eat anchovies on my pizza." C. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium". D. A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with a full glass of water". - Correct answerB. A client who has gout and states, "I can continue to eat anchovies on my pizza." A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant's axilla. B. Pull the pinna of the infant's ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant's rectum. D. Insert the thermometer in front of the infant's tongue. - Correct answerA. Place the tip of the thermometer under the center of the infant's axilla. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution.

D. Children who have varicella are contagious 4 days before the first vesicle eruption. - Correct answerA. Children who have varicella are contagious until vesicles are crusted. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. - Correct answerD. Administer the medication. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. - Correct answerA. Pregabalin A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. - Correct answerA. Prime IV tubing with 0.9% sodium chloride. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. - Correct answerB. Playing with a large plastic truck. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. - Correct answerC. Broiled skinless chicken breast with brown rice. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn's body temperature using a tympanic thermometer. B. FACES pain scale.

C. Auscultate the newborn's apical pulse for 60 seconds. D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence. - Correct answerC. Auscultate the newborn's apical pulse for 60 seconds. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. - Correct answerB. Apply fetal heart rate monitor. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. - Correct answerA. Chest pain A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. - Correct answerA. Quality improvement. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. - Correct answerD. Notify the nursing manager about the suspected alcohol use. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. - Correct answerA. Apply zinc oxide ointment to the irritated area. A nurse is reviewing the facility's safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?

A. "Staff will apply identification band after first bath" B. "I will not publish public announcement about my baby's birth" C. "I can remove my baby's identification band as long as she is in my room" D. "I can leave my baby in my room while I walk in the hallway" - Correct answerB. "I will not publish public announcement about my baby's birth" A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. "Morphine 3 mg SQ every 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) C. "Morphine 3.0 mg sub q every 4 hr. PRN for pain." D. "Morphine 3 mg SC q 4 hr. PRN for pain." - Correct answerB. "Morphine 3 mg Subcutaneous (Unable to read) A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. - Correct answerC. Monitor vital signs. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. "Dehydration is treated with calcium supplements" B. "Dehydration can increase the risk of preterm labor" C. "Dehydration associated gastroesophageal reflux" D. "Dehydration is caused by a decreased hemoglobin and hematocrit" - Correct answerB. "Dehydration can increase the risk of preterm labor" A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) - Correct answerC. Answer might be lower platelets. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals. - Correct answerB. (Answer was the nurse was going to do the interpretation)

A nurse is preparing an in service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? A. Leaving an NG tube clamped after administering oral medication B. Documenting communication with the provider in the progress notes of the clients medical record. C. Administering K via IV bolus D. Placing a yellow bracelet on a client who is at risk of falls. - Correct answerC. Administering K via IV bolus A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? A. Whole grain bread B. Avocados C. Smoked Salmon D. Pepperoni pizza - Correct answerA. Whole grain bread A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Attach the restraint to the bed's side rails B. Request a PRN restraint prescription for clients who are aggressive C. Document the client's condition every 15 min. D. Remove the clients's restraint every 4 hours. - Correct answerC. Document the client's condition every 15 min. 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 therapy. C. A client who is receiving heparin for DVT D. A client who is 1 day postoperative following a vertebroplasty. - Correct answerD. A client who is 1 day postoperative following a vertebroplasty. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency - Correct answerC. Swelling of the face

A nurse is developing a plan for a client who has schizophrenia and experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what is he hearing B. Encourage the client to lie down in a quiet room C. Avoid eye contact with the client D. Refer to the hallucinations as if they were real - Correct answerA. Ask the client directly what is he hearing A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? A. Applying a sterile gown after applying a sterile mask B. Balancing the bottle on the sterile basin while pouring the liquid C. Placing the supplies on the sterile field and leaving a 1 inch perimeter D. Putting on sterile gloves after preparing the sterile field. - Correct answerB. Balancing the bottle on the sterile basin while pouring the liquid A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personal (AP). Which of the following actions should the nurse take first to manager her time effective? A. Develop an hourly time frame for tasks B. Schedule daily activities C. Determine goals of the day D. Delegate tasks to the AP - Correct answerC. Determine goals of the day A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? A. I will decrease my daily protein intake to 15 grams per day B. I will use ibuprofen as needed to control abdominal pain C. I will take sucralfate with meals three times per day D. I will avoid food and beverages that contain caffeine - Correct answerD. I will avoid food and beverages that contain caffeine A nurse is reviewing legal issues in health care with a group of newly licensed nurse. Which of the following recommendations should the nurse make? A. Place copies of incident reports in clients medical records. B. Overestimate clients acuity to prevent short staffing C. Ensure that each client has a living will on file prior to treatment D. Obtain personal professional liability insurance coverage - Correct answerC. Ensure that each client has a living will on file prior to treatment A nurse is providing preoperative teaching about patient controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. The PCA will deliver a double dose of medication when you push the button twice B. You can adjust the amount of pain you receive by pushing on the keypad

C. Continuous PCA infusions is designed to allow fluctuating plasma medication levels D. You should push the button before physical activity to allow maximum pain control - Correct answerD. You should push the button before physical activity to allow maximum pain control A charge nurse is teaching a newly nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following should the charge nurse include? A. The proxy should make health care decisions for the client regardless of the clients ability to do so B. The proxy can make financial decisions if the need arises C. The proxy can make treatments decisions if the client is under anesthesia D. The proxy should manage legal issues for the client - Correct answerC. The proxy can make treatments decisions if the client is under anesthesia A nurse is caring for a client who has a history of depression and i experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the clients perception of the event B. Notify the clients support person C. Help the client identify identify personal strengths D. Teach the client relaxation techniques - Correct answerA. Confirm the clients perception of the event A nurse is caring for a client who has end stage kidney disease. The clients adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary Glaucoma - Correct answerC. Hypertension 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. Encourage the client to spend time in the day room B. Withdraw the clients TV privileges if he does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the client in seclusion when he exhibits signs of anxiety - Correct answerC. Encourage the client to take frequent rest periods A nurse is working with a client who has anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. Lets talk about how you can change your response to stress B. We should establish our roles in the initial session C. Let me show you simple relaxation exercise to manage stress

D. We should discuss resources to implement in your daily life - Correct answerB. We should establish our roles in the initial session A staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper mechanics when lifting. Which of the following images indicates the appropriate use of ergonomic principles? - Correct answerLegs apart, Bending the knees, straight back A nurse is providing teaching to an older adult client about methods of promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1 hr if unable to fall sleep B. Take a 1hr nap during the day C. Perform exercises prior to bedtime D. Eat a light snack before bedtime. - Correct answerD. Eat a light snack before bedtime. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, I do not know what to do. Everything has been happening so quickly. Which of the following responses by the nurse is therapeutic? A. Can you talk about what was happening with your partner at home? B. Why do you think your partner symptoms are progressing so quickly? C. You should make sure your partner takes the prescribed medication D. You did the right thing by bringing your partner in for treatment - Correct answerA. Can you talk about what was happening with your partner at home? A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving cardiac monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% - Correct answerB. A client who has a hip fracture and a new onset of tachypnea 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. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase intake of foods high in gluten - Correct answerA. Consume food high in bran fiber A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension

D. Increased ICP - Correct answerA. Weak femoral pulses A nurse is providing teaching to a client about adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry mouth D. Metallic taste in mouth - Correct answerA. Excessive sweating A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100 /min for the past 15 min. The nurse identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis - Correct answerC. Maternal hypoglycemia A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? A. This test should be performed after your baby is 24 hours old B. A nurse will draw blood from your babies inner elbow C. Your baby will be given 2 ounces of water to drink prior to the test D. This test will be repeated when your bay is 2 month old - Correct answerA. This test should be performed after your baby is 24 hours old A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? A. I can not be a witness for your consent to donate B. Your name can not be removed once you are listed on the organ donors list C. Your desire to be an organ donor must be documented in writing D. You must be at least 21years old to become an organ donor - Correct answerC. Your desire to be an organ donor must be documented in writing A nurse is caring for a client who is at 33 weeks gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions - Correct answerD. Contractions A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take Mg hydroxide for indigestion B. Drink at least 3 L of fluid daily C. Eat 1g/kg of protein per day

D. Consume foods high in K - Correct answerC. Eat 1g/kg of protein per day A charge nurse is teaching new staff members about factors that increase a clients risk to become violent. Which of the following risk factor should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender - Correct answerA. Previous violent behavior A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? A. Folate B. Zinc C. Iron D. Calcium - Correct answerA. Folate A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client? A. Peanut butter sandwich B. Oatmeal with butter C. Chicken noodle soup D. Celery sticks - Correct answerA. Peanut butter sandwich A nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to following medications requires to follow facility procedure in the safety handling of a bio-hazardous material spill? A. Doxorubicin hydrochloride B. Ampicillin Sodium C. Metronidazole D. Phenytoin - Correct answerA. Doxorubicin hydrochloride A nurse in a providers office is reviewing a female clients medical record during a routine visit. The nurse should recommend increased dietary intake of which of the following vitamins? A. Vit D B. Vit K C. Vit B D. Vit A - Correct answerC. Vit B A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritualistic behavior B. Suspicious of others C. Exhibits separation anxiety

D. Preoccupied with aging - Correct answerD. Preoccupied with aging A nurse is caring for a child who has CF and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussions on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure. D. Perform the procedure prior to meals - Correct answerD. Perform the procedure prior to meals A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. HR 58 B. Fasting blood glucose 100 C. Hgb 14 D. WBC 2900 - Correct answerD. WBC 2900 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. Limit your child K intake while she is taking this medication B. You can add the medication to a half a cup of your child favorite juice C. Repeat the dose if your child vomits within 1 hour after taking the medication D. Have your child drink a small glass of water swallowing the medication - Correct answerD. Have your child drink a small glass of water swallowing the medication A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. This type of seizure can be mistaken for daydreaming B. This type of seizure last 30 to 60 seconds C. The child usually has an aura prior to onset D. This type of seizure has a gradual onset - Correct answerA. This type of seizure can be mistaken for daydreaming A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to dietitian? A. An older adult client who has a BMI of 24 B. A client who has a non healing leg ulcer C. AN older adult client who has presbyopia D. A client who has an albumin level of 3.7 - Correct answerB. A client who has a non healing leg ulcer A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client is at risk for aspiration? A. Sitting in a high fowlers position during the feeding

B. A history of gastro esophageal reflux disease C. Receiving a high osmolarity formula D. A residual of 65 ml 1 hr postprandial - Correct answerB. A history of gastro esophageal reflux disease A nurse is caring for several clients on a medical surgical unit. For which of the following nursing activities is it required that the nurse use sterile gloves? A. Inserting a NG-tube B. Administering total parenteral nutrition through a central venous access device C. Initiating an IV D. Performing tracheostomy care - Correct answerD. Performing tracheostomy care A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist one. Which of the following responses should the nurse make? A. We can provide a copy of your records, but the therapist notes are not included. B. I do not think you will benefit from reviewing the therapist notes right now C. Why are you interested in seeing the therapist notes? D. Are you not happy with your treatment? - Correct answerA. We can provide a copy of your records, but the therapist notes are not included. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Monitor FHR via doppler every 30min B. Restrict the clients total fluid intake to 250 ml/hr C. Give the client protamine if signs of magnesium sulfate toxicity occur D. Measure the clients urine output every hour - Correct answerD. Measure the clients urine output every hour A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 sec B. FHR baseline 170/min C. Early decelerations in the FHR D. Temp 37.4 (99.3) - Correct answerB. FHR baseline 170/min A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? A. Decrease the maintenance infusion rate of IV fluid B. Have protamine sulfate available at the bedside C. Reposition the client side to side each hour D. Monitor the client for HTN - Correct answerC. Reposition the client side to side each hour

A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse palm to take during the orientation phase of the relationship? A. Determine previous coping skills used by the client B. Establish the responsibilities of the nurse and client C. Facilitate the clients problem solving skills D> Assist the client in expressing alternative behavior - Correct answerB. Establish the responsibilities of the nurse and client A nurse is reviewing the medical record of 4 clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48 hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1. D. A client who is taking bumetanide and has potassium level of 3.6 - Correct answerC. A client who is taking warfarin and has an INR of 1. A nurse is caring for a client who is 2 hour pos op following a cardiac catheterization. Which of the following is the priority assessment finding? A. Report of burning sensation at the insertion site B. Absence of pedal pulse in the affected extremity C. Urinary output 25 ml/hr D. SpO2 91% - Correct answerB. Absence of pedal pulse in the affected extremity A nurse in a mental facility receives change of shift report for 4 clients. Which of the following clients should the nurse plan to assess first? A. A client placed in restraints due to aggressive behavior B. A client who will be receiving her first ECT treatment today C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety D. A newly admitted client who has a history of 4.5kg weigth loss in the past 2 months - Correct answerA. A client placed in restraints due to aggressive behavior A nurse is providing discharge teaching about a car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. I can turn my baby car seat around when she weighs 15 pounds B. I can place my baby in the front seat with the airbag turned off C. I will place my baby in a forward facing car seat in my back seat D. I will position my baby at a 45 degree angle in the car seat - Correct answerD. I will position my baby at a 45 degree angle in the car seat A nurse in a clinic is assessing a 6 month old infant. Which of the following findings should the nurse report to the provider? A. Pulse 140 min B. Closed anterior fontanel C. RR 26 min

D. Abdominal breathig - Correct answerB. Closed anterior fontanel

1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client's peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client's condition every 15 minutes - Correct answerD. Document the client's condition every 15 minutes 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 clients exhibits impulse behavior B. The client might act seductively C. The client is exceptionally clingy to others D. The client is overly concerned about minor details - Correct answerA. The clients exhibits impulse behavior A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? A. Monitor the dorsalis pedis pulse every 15 min B. Keep the client NPO for 24 hours C. Place the client in Fowlers position D. Maintain struct bedrest for th first 12 hours - Correct answerA. Monitor the dorsalis pedis pulse every 15 min A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy? A. Peripheral neuropathy B. Osteoarthritis C. Abdominal aortic aneurysm D. Phlebitis - Correct answerA. Peripheral neuropathy A nurse in an ED is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first? A. Calculate fluid replacement based on VS and UOP B. Determine the location and depth of the burns C. Check the mouth for soot and smoky breath D. Administer antibiotics prophylactically - Correct answerC. Check the mouth for soot and smoky breath 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. Perform range of motion exercises to the clients extremities B. Place the clients tight hand in a supination position C. Change the clients position every 2 hours D. Maintain NPO status for the client - Correct answerD. Maintain NPO status for the client A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit pf RBC. Which of the following actions should the nurse take? A. Administer the blood via a 21 gauge IV needle B. Set the IV infusion pump to administer the blood over 6 hours C. Check the clients VS from the previous Shift prior to the initiation of the transfusion D. Flush the blood administration tubing with NS prior to transfusion - Correct answerD. Flush the blood administration tubing with NS prior to transfusion Intra-dermal Injections areas. A. Buttocks B. Upper back C. Hamstring - Correct answerB. Upper back A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? SATA A. Impulse control difficulty B. Left Hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness - Correct answerA. Impulse control difficulty B. Left Hemiplegia C. Loss of depth perception E. Lack of situational awareness A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan the right to see objects on the right side of her body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the wheelchair on the client's left side. - Correct answerB. Place the bedside table on the right side of the bed. A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? SATA A. have suction equipment available B. Feed client thickened liquids C. Place foods on the unaffected side of the mouth D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed. - Correct answerA. have suction equipment available

B. Feed client thickened liquids C. Place foods on the unaffected side of the mouth E. Teach the client to swallow with her neck flexed. A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client's plan of care? SATA A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time - Correct answerA. Speak to the client at a slower rate B. Assist the client to use flash card with pictures E. Give instructions one step at a time A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception - Correct answerC. Inability to recognize familiar objects A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABG's. D. Administer benzocaine spray. - Correct answerA. Position the client in an upright position, leaning over the bedside table. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis - Correct answerB. Respiratory alkalosis A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms - Correct answerD. Bronchospasms

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? SATA A. Oxygen equipment B. Incentive spirometer C. Sterile dressing D. Suture removal kit E. Pulse oximeter - Correct answerA. Oxygen equipment C. Sterile dressing E. Pulse oximeter A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? SATA A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site - Correct answerA. Dyspnea C. Fever D. Hypotension A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? SATA A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing - Correct answerA. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site. C. Place tape around the insertion site. D. Assess respiratory status. - Correct answerB. Apply sterile gauze to the insertion site. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? SATA A. Gentle Constant bubbling in the suction control chamber B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration C. Exposed sutures without dressing.

D. Drainage system upright at chest level - Correct answerA. Gentle Constant bubbling in the suction control chamber B. Rise and fall in the level of water in the water seal chamber with inspiration and expiration A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on it left side. B. Use the incentive spirometer. C. Cough at regular intervals. D. Perform the valsalva maneuver - Correct answerD. Perform the valsalva maneuver A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA A. Encourage the client to cough every 2 hours B. Check the continuous bubbling in th suction chamber C. Strip the drainage tubing every 4 hours. D. Clamp the tube once a day. E. Obtain a chest x-ray - Correct answerA. Encourage the client to cough every 2 hours B. Check the continuous bubbling in th suction chamber E. Obtain a chest x-ray A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator. D. "It delivers a preset ventilatory rate and tidal volume to the client." - Correct answerB. "It allows preset pressure delivered during spontaneous ventilation." A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevation blood pressure. - Correct answerB. Pale skin E. Elevation blood pressure. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings ever 8 hours.