Saunder's Comprehensive NCLEX Review Practice Questions with correct answers graded A+ alr, Exams of Nursing

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Which teaching method is most effective when providing instruction to members of special populations?

1. Teach-back
2. video instruction
3. written materials
4. verbal explanation - correct answer 1. Teach-back Rationale: When providing education to members of special populations, return explanation and demonstration (teach-back) of are particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming the client understands the instructions. Which health concerns should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply:
5. cancer
6. obesity
7. hypertension
8. heart disease
9. hypothyroidism
10. diabetes mellitus - correct answer 1, 2, 3, 4, 6 Rationale: obesity, diabetes mellitus, hypertension, heart disease, asthma, and cancer are prevalent among African Americans. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes info about which measure that's related to a newborn complication within this ethnic group?
11. safe sleeping
12. car seat safety
13. breast-feeding
14. baby-proofing - correct answer 1. Safe sleeping Rationale: The native Hawaiian population has a disproportionately higher rate of infant mortality compared with other ethnic groups. Sudden Infant Death Syndrome (SIDS) is a major cause of infant mortality. Safe sleeping is an important measure to prevent this newborn complication. The nurse is planning care for an assigned client. The nurse should include info in the plan of care about the prevention of HIV for which individuals specifically at risk?

Saunder's Comprehensive NCLEX

Review Practice Questions with correct

answers graded A+ already passed!

1. lesbian persons
2. men-who-have-sex-with-men (MSM)
3. women-who-have-sex-with-women (WSW)
4. Female-To-Male (FTM) transgender persons - correct answer 2. MSM Rationale: MSM (men who have sex with men) are at a higher risk for HIV and AIDS. Which therapeutic communication technique is most helpful when working with transgender persons?
5. using open-ended questions
6. using their first name to address them
7. using pronouns associated with birth sex
8. anticipating the client's needs and making suggestions - correct answer 1. Using open-ended questions Rationale: The use of open-ended questions is the most helpful in communicating with transgender persons because it assists in refraining from judgment and allows the client the opportunity to express their thoughts and feelings. Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply:
9. male-to-female (MTF)
10. female-to-male (FTM)
11. men-who-have-sex-with-men (MSM)
12. women-who-have-sex-with-men (WSM)
13. women-who-have-sex-with-women (WSW) - correct answer 1, 2, 4, 5 Rationale: Transgender persons who have undergone sexual reassignment surgery should have the respective preventive screenings. WSW and WSM should also have screenings. The nurse is volunteering with an outreach program to provide basic healthcare for homeless people. Which finding, if noted, should be addressed first?
14. BP 154/
15. visual acuity of 20/200 in both eyes
16. random blood glucose level of 206
17. complaints of pain associated with numbness and tingling in both feet - correct answer 4. complaints of pain associated with numbness and tingling in both feet Rationale: With this population, the complaints of pain associated with numbness and tingling should be addressed first. If the client perceives value to the service provided, they will be likely to provide follow-up care. While the bp, blood glucose, and vision are concerning, the client's stated concern should be addressed first.

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed?

1. Glipizide
2. Lisinopril
3. Metformin
4. Beclomethasone - correct answer 1. Glipizide Rationale: Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which is a safety risk to the homeless population. Lisinopril is an angiotensin-converting enzyme inhibitor. Although there are side effects that should be included in discharge instructions, there is less of a threat to safety with this medication and the benefits to it are important. Metformin is an oral biguanide and is used for type 2 diabetes mellitus. Hypoglycemia is less of a concern with this medication compared with other oral hypoglycemics. Beclomethasone is an inhaled corticosteroid used for obstructive lung disease, and although there are side effects the client should know about, there is not a particular safety risk associated with this medication for the homeless person. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete?
5. the history
6. the physical assessment
7. the nursing plan of care
8. the readmission risk assessment - correct answer 1. the history Rationale: intellectually disabled clients tend to be poor historians, and it may take more time to ask questions in different ways when collecting the history data. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond?
9. "health care is very limited in the prison setting"
10. "living in a prison isn't different than living at home"
11. "living in a prison can predispose a person to different health conditions"
12. "living in a prison is similar to living in a condominium complex or dorm" - correct answer 3. "living in a prison can predispose a person to different health conditions" Rationale: the environment of a prison can predispose a person to different health conditions. Option 1 does not address the client's question and options 2 and 4 convey incorrect information. A nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply:
13. asthma
14. claustrophobia

3. sleep problems
4. bipolar disorder
5. aggressive behavior
6. ADHD - correct answer 3, 4, 5, 6 Rationale: foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, PTSD, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder. Claustrophobia and asthma are not specifically associated with foster children. The nurse is caring for a female client in the ED who presents with a complaint of fatigue and SOB. Which physical assessment findings, if noted by the nurse, warrant a need for follow up?
7. reddened sclera of the eyes
8. dry flaking noted on the scalp
9. a reddish-purple mark on the neck
10. a scaly rash noted on the elbows and knees - correct answer 3. a reddish-purple mark on the neck Rationale: The client should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, SOB, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise including PTSD, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self-esteem, and alcohol and drug abuse. Reddened sclera, a dry rash on the elbows, and flaking of the scalp do not indicate abuse. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?
11. hypertension
12. hyperlipidemia
13. substance abuse disorder
14. PTSD - correct answer 4. PTSD Rationale: PTSD is extremely common in this population. Identifying and treating mental health disorders assists in lowering the suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance abuse disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy. Hypertension and hyperlipidemia are important but not priority; the risk of suicide and other safety concerns associated with PTSD are the priority for this population. The nurse caring for a refugee considers which health care need a priority for this client?

1. access to housing
2. access to clean water
3. access to transportation
4. access to mental health care services - correct answer 4. access to mental health care services Rationale: Mental health problems are the primary issue for this population as a result of tortuous events. While all the other options are important, they do not address the specific needs of this special population. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?
5. arranging for home health care
6. focusing on managing a single illness at a time
7. communicating with one provider only to avoid confusion for the client
8. allowing the client to teach a support person about their treatment regimen - correct answer 1. arranging for home health care Rationale: Nursing follow-up visits are important in promoting health for individuals with chronic illness, therefore, arranging for home health care is an important strategy. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?
9. The client fell out of bed.
10. The client climbed over the side rails.
11. The client was found lying on the floor.
12. The client became restless and tried to get out of bed. - correct answer 3. the client was found lying on the floor Rationale: The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The other options are interpretations of the situation, not facts. A client is brought to the ED by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
13. obtain a court order for the surgical procedure
14. ask the EMS team to sign the informed consent
15. transport the victim to the operating room for surgery
16. call the police to identify the client and notify the family - correct answer 3. transport the victim to the operating room for surgery

Rationale: two situations where informed consent is not needed are when an emergency is present and delaying treatment in order to get informed consent would result in injury or death to the client, or when the client waives the right to get informed consent. A nurse has just assisted a client back to bed after a fall. The nurse and primary healthcare provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

1. reassess the client
2. conduct a staff meeting to describe the fall
3. contact the nursing supervisor to update info regarding the fall
4. document in the nurse's notes that an occurrence report was completed - correct answer 1. reassess the client Rationale: after a client's fall, the nurse must frequently reassess the client. Their fall should be treated as private information and given on a "need to know" basis. The nurse does not need to put the completion of the occurrence report in the nurse's notes. A nurse arrives at work and is told to float to the ICU for the day because they're understaffed and need additional nurses to care for clients. The nurse has never worked in the ICU. The nurse should take which best action?
5. refuse to float to the ICU because of lack of unit orientation
6. clarify the ICU client assignment with the team leader to ensure it's a safe assignment
7. ask the nursing supervisor to review the hospital policy on floating
8. submit a written protest to nursing administration, and then call the hospital lawyer - correct answer 2. clarify the ICU client assignment with the team leader to ensure it's a safe assignment Rationale: Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performed tasks. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around her upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
9. call security
10. call police
11. call the nursing supervisor
12. lock the coworker in the medication room until help is obtained - correct answer 3. call the nursing supervisor Rationale: the nurse practice act requires reporting impaired nurses. The nurse should report it to the nursing supervisor.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

1. "I will sign as a witness to your signature"
2. "you will need to find a witness on your own"
3. "whoever is available at the time will sign as a witness for you"
4. "I will call the nursing supervisor to seek assistance regarding your request" - correct answer 4. "I will call the nursing supervisor to seek assistance regarding your request" Rationale: Living wills are required to be in writing and signed by the client, and their signature must be witnessed or notarized. Laws regarding living wills vary by state to state, and many states inhibit any employee from being a witness. The nurse has made an error in documentation of dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the MAR that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which actions to correct the MAR? Select all that apply:
5. complete and file an occurrence report
6. right-click on the entry and modify it to reflect the correct information
7. document the correct information and end with the nurse'e signature and title
8. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg
9. document in a nurse's note in the client's record detailing the corrected information. - correct answer 2, 3, 4, 5 Rationale: Electronic health records will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error, they should follow agency protocols to correct the error. In the MAR the nurse can right click on the entry and modify it to correct it. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the record. An occurrence report is not needed in this situation. Which identifies accurate nursing documentation notations? Select all that apply:
10. The client slept through the night
11. Abdominal wound dressing is dry and intact without drainage
12. The client seemed angry when awakened for vital sign measurement
13. The client appears to become anxious when it is time for respiratory treatments
14. The client's left lower medial leg wound is 3cm in length without redness, drainage, or edema - correct answer 1, 2, 5

Rationale: Factual documentation has descriptive, objective information about what the nurse sees, feels, hears, or smells. Inferences and vague terms are not acceptable because its an opinion/not factual. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of this client right?

1. performing a procedure without consent
2. threatening to give a client medication
3. telling the client that he or she cannot leave the hospital
4. observing care provided to the client without the client's permission - correct answer
5. observing care provided to the client without the client's permission Rationale: invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated?
6. Libel
7. Slander
8. Assault
9. Negligence - correct answer 2. Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation either in writing (libel) or verbally (slander). An older woman is brought to the ED for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he gets home from work. Which is the most appropriate nursing response?
10. "Oh, really? I will discuss this situation with your son"
11. "Lets talk about ways you can manage your time to prevent this from happening"
12. "Do you have any friends who could help you out until you resolve these issues with your son?"
13. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay" - correct answer 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay" Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases.

The nurse calls the primary hc provider regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the primary hc provider, and the medication is due to be administered. Which action should the nurse take?

1. contact the nursing supervisor
2. administer the dose prescribed
3. hold the medication until the primary hc provider can be contacted
4. administer the recommended does until the primary hc provider can be located - correct answer 1. contact the nursing supervisor Rationale: If the primary care provider writes a prescription that requires clarification, it is the nurse's responsibility to contact them. If that is not able to happen, the nurse should contact the nursing supervisor or nurse manager for further clarification as to what the next step should be. The nurse employed in a hospital is waiting to receive a report from the lab from the fax machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photo. Which is the most appropriate nursing action?
5. call the police
6. cut up the photo and throw it away
7. call the nursing supervisor and report the occurrence
8. call the lab and ask for the name of the individual who sent the photo - correct answer
9. call the nursing supervisor and report the occurrence The nurse is assigned to care for 4 client. In planning client rounds, which client should the nurse assess first?
10. a post-op client preparing for discharge with a new medication
11. a client requiring daily dressing changes of a recent surgical incision
12. a client scheduled for a chest x-ray after an insertion of a nasogastric tube
13. a client with asthma who requested a breathing treatment during the previous shift - correct answer 4. a client with asthma who requested a breathing treatment during the previous shift Rationale: airway is always the highest priority, and since the client had difficulty breathing during the previous shift they should assess them first. The nurse employed in an ED is assigned to triage clients coming to the ED for treatment on the evening shift. The nurse should assign priority to which client?
14. a client complaining of muscle aches, headache, and a history of seizures
15. a client who twisted her ankle when rollerblading and is requesting medication for pain
16. a client with a minor laceration on the index finger sustained while cutting an eggplant
17. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce - correct answer 4. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Rationale: clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, acute neurological defects, or who have sustained chemical splashes to the eyes are classified as emergent and are priority. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the hc facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

1. each staff member is assigned a specific task for a group of clients
2. a staff member is assigned to determine the client's needs at home and begin discharge planning
3. a single RN is responsible for providing care to a group of 6 clients with the help of assistive personnel
4. an RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients - correct answer 4. an RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients Rationale: in team nursing, nursing personnel are led by a RN leader in providing care to a group of clients. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?
5. a client who is ambulatory demonstrating steady gait
6. a post-op client who has just received an opioid pain med
7. a client scheduled for PT for their first crutch-walking session
8. a client with a WBC count of 14,000 mm and a temp of 38.4 C - correct answer 4. a client with a WBC count of 14,000 and a temp of 38.4 C Rationale: The nurse should plan to care for the client who has an elevated WBC count and a fever first because their needs are the priority. The nurse is giving a bed bath to an assigned client when an AP enters the client's room and tells the nurse another assigned client is in pain and needs pain meds. Which is the most appropriate nursing action?
9. finish the bed bath and then administer the pain med to the other client
10. ask the AP to find out when the last pain med was given to the client
11. ask the AP to tell the client in pain the med will be administered as soon as the bed bath is done
12. cover the client, raise the side rails, tell the client you'll return soon, and give the pain med to the other client - correct answer 4. cover the client, raise the side rails, tell the client you'll return soon, and give the pain med to the other client Rationale: the nurse should provide safety to the client receiving the bed bath and prepare to give the pain med.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An AP is resistive to the change and is not taking an active part to facilitate the process of change. Which is the best approach in dealing with the AP?

1. Ignore the resistance
2. exert coercion on the AP
3. provide a positive reward system for the AP
4. confront the AP to encourage verbalization of feelings regarding the change - correct answer 4. confront the AP to encourage verbalization of feelings regarding the change Rationale: confrontation is an important strategy to meet resistance head-on. The RN is planning client assignments for the day. Which is the most appropriate assignment for an AP?
5. a client requiring a colostomy irrigation
6. a client receiving continuous tube feedings
7. a client who requires urine specimen collections
8. a client with difficulty swallowing food and fluids - correct answer 3. a client who requires urine specimen collections Rationale: The AP is skilled in the procedure of a urine specimen collection. Colostomy irrigations and tube feedings are not performed by APs because they're invasive procedures, and the client with difficulty swallowing is at risk for aspiration. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply:
9. open doors to client rooms
10. move beds away from windows
11. close window shades and curtains
12. place blankets over client confined to beds
13. relocate ambulatory clients from the hallways back into their rooms - correct answer 2, 3, 4 The nurse employed in a LTC facility is planning assignments for the clients in a nursing unit. The nurse needs to assign 4 clients and has a LPN and 3 APs on a nursing team. Which client would the nurse most appropriately assign to the LPN?
14. a client who requires a bed bath
15. an older client requiring frequent ambulation
16. a client who needs hourly vital sign measurements
17. a client requiring abdominal wound irrigations and dressing changes every 3 hours - correct answer 4. a client requiring abdominal wound irrigations and dressing changes every 3 hours

Rationale: giving a bed bath, assisting with frequent ambulation, and taking vitals can be done by an AP. The LPN is trained in wound irrigations and dressing changes so this is an appropriate assignment for them. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply:

1. the acuity level of the clients
2. specific responses from the staff
3. the clustering of the rooms on the unit
4. the number of anticipated client discharges
5. client needs and worker needs and abilities - correct answer 1, 5 Rationale: staff requests, convenience in clustering of rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
6. weight loss and dry skin
7. flat neck and hand veins and decreased urinary output
8. an increase in bp and increased respirations
9. weakness and decreased central venous pressure (CVP) - correct answer 3. an increase in bp and increased respirations Rationale: Assessment findings associated with fluid volume excess are cough, dyspnea, crackles, tachypnea, tachycardia, elevated bp, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered LOC, and decreased hematocrit. The nurse reviews a client's record and determines that the client is at risk for developing a K+ deficit if which situation is documented?
10. sustained tissue damage
11. requires nasogastric suction
12. has a history of addison's disease
13. uric acid level of 9.4 mg/dl (557 mcmol/L) - correct answer 2. requires nasogastric suction Rationale: the normal serum K+ level is 3.5 to 5.0. K+-rich GI fluids are lost through GI suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The nurse reviews a client's electrolyte lab report and notes the client's K+ level is 2. mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the ECG as a result of the lab value? Select all that apply:

1. U waves
2. absent P waves
3. inverted T waves
4. depressed ST segment
5. widened QRS complex - correct answer 1, 3, 4 Rationale: A serum K+ level lower than 3.5 indicates hypokalemia. K+ deficit is an electrolyte imbalance that can be potentially life-threatening. ECG changes include shallow, flat, or inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not present in hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and hypermagnesemia. Potassium chloride intravenously is prescribed for a client with HF experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the K+? Select all that apply:
6. obtain an IV infusion pump
7. monitor urine output during administration
8. prepare the medication for bolus administration
9. monitor the IV site for signs of infiltration or phlebitis
10. ensure the medication is diluted in the appropriate volume of fluid
11. ensure the bag is labeled so it reads the volume of K+ in the solution - correct answer 1, 2, 4, 5, 6 Rationale: potassium chloride administered IV must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). The IV bag containing the potassium chloride should always be labeled with the amount of potassium it contains. The IV site is monitored closely, because it's irritating to the veins and there's a risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors for urine output during administration and should contact the doctor if urinary output is less than 30 mL/hour. The nurse is assessing a client with lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
12. twitching
13. hypoactive bowel sounds
14. negative Trousseau's sign
15. hypoactive deep tendon reflexes - correct answer 1. twitching Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5. A serum calcium level under 9 indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include neuromuscular excitability, muscle cramps, twitching, tetany,

seizures, irritability, and anxiety. GI symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dl (2mmol/L). Which patterns would the nurse watch for on the ECG? Select all that apply:

1. U waves
2. widened T waves
3. Prominent U wave
4. Prolonged QT interval
5. Prolonged ST segment - correct answer 4, 5 Rationale: A client with Chron's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5, and a serum calcium level lower than 9 indicates hypocalcemia. ECG changes that occur in a client with hypocalcemia include a prolonged QT interval, and prolonged ST segment. A shortened ST segment and wider T wave occur with hypercalcemia. ST segment depression and prominent U wave occurs with hypokalemia. The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the K+ level is 5.7 mEq/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the lab value? Select all that apply:
6. ST depression
7. prominent U wave
8. tall peaked T waves
9. prolonged ST segment
10. widened QRS complexes - correct answer 3, 5 Rationale: The client with chronic kidney disease is at risk for hyperkalemia. The normal K+ level is 3.5 to 5. A serum K+ level greater than 5 indicates hyperkalemia. ECG changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave are signs of hypokalemia. A prolonged ST segment occurs in hypocalcemia. Which client is at risk for the development of a Na+ level of 130 mEq/L?
11. the client who is taking diuretics
12. the client with hyperaldosteronism
13. the client with Cushing's syndrome
14. the client who's taking corticosteroids - correct answer 1. the client who is taking diuretics Rationale: The normal serum sodium level is 135 to 145. A serum sodium level of 130 indicates hyponatremia. Hyponatremia can occur in a client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is caring for a client with HF who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

1. muscle twitches
2. decreased urinary output
3. hyperactive bowel sounds
4. increased specific gravity of the urine - correct answer 3. hyperactive bowel sounds Rationale: The normal serum sodium level is 135 to 145. Hyponatremia is evidenced by a serum sodium level lower than 135. Hyperactive bowel sounds indicate hyponatremia. Other signs of hyponatremia are muscle weakness, increased urinary outpur, and decreased specific gravity of the urine. Muscle twitches, decreased urinary output, and increased specific gravity of the urine are all signs of hypernatremia. The nurse reviews a client's lab report and notes that the client's serum phosphorus is 1.8 mg/dL. Which condition most likely caused this serum phosphate level?
5. malnutrition
6. renal insufficiency
7. hypoparathyroidism
8. tumor lysis syndrome - correct answer 1. malnutrition Rationale: the normal serum phosphate level is 3.0 to 4.5. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative signs of hyperphosphatemia. The nurse is reading a primary hc provider's progress notes in the client record and reads that they've documented "insensible fluid loss of 800 mL daily". The nurse makes a notation that insensible fluid loss occurs through which type of excretion?
9. urinary output
10. wound drainage
11. integumentary output
12. the GI tract - correct answer 3. integumentary output Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and GI tract losses. The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
13. a client with an ileostomy
14. a client with hf
15. a client on long-term corticosteroid therapy

4. a client receiving frequent wound irrigations - correct answer 1. a client with an ileostomy Rationale: a fluid volume deficit occurs when the fluid intake is not sufficient to meet the needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with hf or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess. The nurse caring for a client who has been receiving IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
5. weight loss and poor skin turgor
6. lung congestion and increased hr
7. decreased hematocrit and increased urine output
8. increased respirations and increased bp - correct answer 1. weight loss and poor skin turgor Rationale: a fluid volume deficit occurs when the fluid intake is not sufficient enough to meet the fluid needs of the body. Assessment findings in a client with fluid volume deficit include increased respirations, increased HR, decreased CVP, weight loss, poor skin turgor, dry mucus membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered LOC. Lung congestion, increased urinary output, and increased BP are all associated with fluid volume excess. On review of the client's medical records, the nurse determines that which client is at risk for fluid volume excess?
9. the client taking diuretics who has tenting of the skin
10. the client with an ileostomy from a recent abdominal surgery
11. the client who requires intermittent GI suctioning
12. the client with kidney disease and a 12 - year history of diabetes mellitus - correct answer 4. the client with kidney disease and a 12 - year history of diabetes mellitus Rationale: a fluid volume excess may be caused by decreased kidney function, HF, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an Ileostomy, and the client requiring GI suctioning are all at risk for fluid volume deficit. Which client is at risk for the development of a K+ level of 5.5 mEq/L?
13. the client with colitis
14. the client with Cushing's syndrome
15. the client who has been overusing laxatives
16. the client who has been sustained in a traumatic burn - correct answer 4. the client who has been sustained in a traumatic burn

Rationale: The normal K+ level is 3.5 to 5.0. A K+ level higher than 5 indicates hyperkalemia. Hyperkalemia may occur in clients who experience cellular shifting of K+ in the early stages of massive cell destruction such as with burns, trauma, sepsis, or metabolic or respiratory acidosis. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 30 mmHg, and HCO- 3 of 20 mEq/L. The nurse analyzes these results as which condition?

1. metabolic acidosis, compensated
2. respiratory alkalosis, compensated
3. metabolic alkalosis, uncompensated
4. respiratory acidosis, uncompensated - correct answer 2. respiratory alkalosis, compensated Rationale: the normal pH is 7.35 to 7.45. In this condition the pH is on the high end and the PaCO2 is low. Since the pH is elevated, it is alkalosis. This condition indicates respiratory alkalosis and because the pH has returned to a normal range, compensation has occurred. The nurse is caring for a client with an NG tube attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?
5. metabolic acidosis
6. metabolic alkalosis
7. respiratory acidosis
8. respiratory alkalosis - correct answer 2. metabolic alkalosis Rationale: metabolic alkalosis is a deficit of hydrogen ions or excess bicarb due to the accumulation of bicarb or from a loss of acid. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarb intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via NG suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/min. The ECG monitor displays tachycardia, with a HR of 120 bpm. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following?
9. A decreased pH and an increased CO
10. An increased pH and a decreased Co
11. A decreased pH and a decreased HCO3-
12. An increased pH with an increased HCO3- - correct answer 4. An increased pH with an increased HCO3- Rationale: clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from the loss of gastric acid, thus causing the pH and the

HCO- 3 to increase. Symptoms experienced by the client would include a decrease in the RR and depth and tachycardia. A decreased pH and increased CO2 indicates respiratory acidosis. An increased pH and decreased Co2 indicates respiratory alkalosis. A decreased pH and decreased HCO3- indicates metabolic acidosis. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH 7.53, PaO2 72 mmHg, PaCO2 32 mmHg, and HCO- 3 28 mEq/L. Which conclusion about the client should the nurse make?

1. the client has acidotic blood
2. the client is probably overreacting
3. the client has fluid volume overload
4. the client is probably hyperventilating - correct answer 4. the client is probably hyperventilating Rationale: the ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply:
5. respirations that are shallow
6. respirations that are increased in rate
7. respirations that are abnormally slow
8. respirations that are abnormally deep
9. respirations that cease for several seconds - correct answer 2, 4 Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90, and HCO3- is 22. the nurse interprets the results as indicating which condition?
10. Metabolic Acidosis with compensation
11. Respiratory Acidosis with compensation
12. Metabolic Acidosis without compensation
13. Respiratory Acidosis without compensation - correct answer 4. Respiratory Acidosis without compensation Rationale: The normal pH is 7.35 to 7.45 and the normal PaCO2 is 35 to 45. The normal HCO-3 level is 21 to 28. The bicarb level is still within normal limits, and the pH is not within normal limits, therefore it is respiratory acidosis that is uncompensated.

The nurse notes that a client's ABG results reveal a pH of 7.50 and a PaCO2 of 30. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply:

1. nausea
2. confusion
3. bradypnea
4. tachycardia
5. hyperkalemia
6. lightheadedness - correct answer 1, 2, 4, 6 Rationale: respiratory alkalosis is caused by conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and tingling of the extremities. Hyperventilation (tachypnea) occurs. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyses the results and determines that the client is experiencing respiratory acidosis. Which results validate the nurse's findings?
7. pH 7.25, PaCO2 50
8. pH 7.35, PaCO2 40
9. pH 7.5, PaCO2 52
10. pH 7.51, PaCO2 28 - correct answer 1. pH 7.25, PaCO2 50 Rationale: atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45, and the normal PaCO2 is 35 to 45. In respiratory acidosis, the pH is decreased and the PaCO2 is elevated. The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.5 and a PaCO2 of 30. The nurse has determined that the client is experiencing respiratory alkalosis. Which lab value would most likely be noted in this condition?
11. Na+ level of 145
12. K+ level of 3
13. Mg level of 1.
14. Phosphorus level of 3 - correct answer 2. K+ level of 3 Rationale: respiratory alkalosis is a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis are lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

1. respiratory acidosis from inadequate ventilation
2. respiratory alkalosis from anxiety and hyperventilation
3. metabolic acidosis from calcium loss due to broken bones
4. metabolic alkalosis from taking analgesics containing base products - correct answer
5. respiratory acidosis from inadequate ventilation Rationale: respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will most likely have difficulty breathing adequately and is at risk for hypoventilation and respiratory acidosis. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?
6. adding a dose of heparin sodium
7. holding the next dose of warfarin
8. increasing the next dose of warfarin
9. administering the next dose of warfarin - correct answer 2. holding the next dose of warfarin Rationale: the normal PT is 11-12.5 seconds. A therapeutic PT level is 1.5 - 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse should anticipate that the client would not receive further doses at this time. A staff nurse is precepting a new grad nurse who is assigned to care for a client with chronic pain. Which statement, if made by the new grad nurse, indicates the need for further teaching regarding pain management?
10. "I will be sure to ask my client what his pain level is on a scale of 1 to 10"
11. "I know that I should follow up after giving medication so I make sure it's effective"
12. "I will be sure to cue in any indicators that the client may be exaggerating their pain"
13. "I know that pain in the older client might manifest as sleep disturbances or depression" - correct answer 3. "I will be sure to cue in any indicators that the client may be exaggerating their pain" A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
14. 3 mg/dL (1.08 mmol/L)
15. 15 mg/dL (5.4 mmol/L)
16. 29 mg/dL (10.44 mmol/L)
17. 35 mg/dL (12.6 mmol/L) - correct answer 2. 15 mg/dL (5.4 mmol/L) Rationale: the normal BUN level is 10 - 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3

mg/dL (1.08 mmol/L) reflects a lower than normal value, which may occur with fluid overload. The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?

1. taking a rectal temp for a client who has undergone nasal surgery
2. taking an oral temp for a client with a cough and nasal congestion
3. taking an axillary temp for a client who has just consumed hot coffee
4. taking a temp on the neck behind the ear using an electronic device for a client who is diaphoretic - correct answer 2. taking an oral temp for a client with a cough and nasal congestion Rationale: an oral temp should be avoided if the client has nasal congestion. One of the other methods of measuring the temp should be used according to the equipment available. Taking a rectal temp for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available, but if not, a rectal temp is appropriate. Taking an axillary temp on a client who has just consumed coffee is also acceptable, however, the axillary measurement is least reliable and other methods should be used if available. If electronic equipment is available and the client is diaphoretic, it is acceptable to measure the temp on the neck behind the ear, avoiding the forehead. A client is receiving a continuous IV infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?
5. discontinuing the heparin infusion
6. increasing the rate of the heparin infusion
7. decreasing the rate of the heparin infusion
8. leaving the rate of the heparin infusion as it is - correct answer 4. leaving the rate of the heparin infusion as it is Rationale: The normal aPTT varies between 30 and 40 seconds. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 45 seconds or greater than 100 seconds. Thus, the client's value is within the therapeutic range and the dose should not be changed. A client with a history of heart failure is due for a morning dose of furosemide. Which serum K+ level, if noted in the client's lab report, should be reported before administering the dose of furosemide?
9. 3.2 mEq/L
10. 3.8 mEq/L
11. 2 mEq/L
12. 8 mEq/L - correct answer 1. 3.2 mEq/L

Rationale: The normal serum K+ level in the adult is 3.5 to 5. The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low K+ level and a history of cardiac problems could precipitate ventricular dysrhythmias The remaining options are within the normal range. Several lab tests are prescribed for a client, and the nurse reviews the results of the tests. Which lab result should the nurse report? Select all that apply:

1. platelets 35,000
2. sodium 150 mEq/L
3. K+ 5.0 mEq/L
4. segmented neutrophils 40% (0.40)
5. serum creatine 1 mg/dL
6. white blood cells 3,000 - correct answer 1, 2, 4, 6 Rationale: the normal values include the following: platelets 150,000-400,000, sodium 135 - 145, K+ 3.5-5, segmented neutrophils 62%-68%, serum creatinine male 0.6-1.2 mg/dL, serum creatinine female 0.5-1.1 mg/dL, and WBC 5,000-10,000. The platelet level noted is low, the sodium level is high, the K+ level is normal, the segmented neutrophil level is low, the serum creatinine level noted is normal, and the WBC level is low. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's med history and determines it is necessary to contact the primary hc provider if the client is also taking which meds? Select all that apply:
7. warfarin
8. glimepiride
9. amlodipine
10. simvastatin
11. atorvastatin - correct answer 1, 2, 3 Rationale: nonsteroidal antiinflammatory drugs (NSAIDS) can amplify the effects of anticoagulants. Therefore, these meds should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral antidiabetic agent like glimepiride, and these meds should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker like amlodipine, so this combination should be avoided. There is no known interaction between ibuprofen and simvastatin and atorvastatin. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. on the basis of this test result, the nurse plans to teach the client about the need for which measure?
12. avoiding infection
13. taking in adequate fluids
14. preventing and recognizing hypoglycemia
15. preventing and recognizing hyperglycemia - correct answer 4. preventing and recognizing hyperglycemia

Rationale: the normal reference range for the glycosylated hemoglobin A1c is is less than 6%. This test measures the amount of glucose that has become permanently bound to the RBC from circulating glucose. RBC like for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients why have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL. elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. The nurse is caring for a client with a diagnosis of breast cancer who is immunocompromised. The nurse would consider implementing neutropenic precautions if the client's WBC count was which value?

1. 2,000
2. 5,800
3. 8,400
4. 11,500 - correct answer 1. 2,000 Rationale: the normal WBC count ranges from 5,000 to 10,000. The client who has a decrease in the number of WBCs is immunocompromised. The nurse implements neutropenic precautions when the client's value falls significantly below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values. A client brought to the ED states that he has accidentally been taking 2x his prescribed dose of warfarin for the past week. After noting the client has no signs of obvious bleeding, the nurse plans to take which action?
5. prepare to administer an antidote
6. draw a sample for type and crossmatch and transfuse the client
7. draw a sample for an aPTT level
8. draw a sample for a PT and international normalized ratio (INR) - correct answer 4. draw a sample for a PT and international normalized ratio (INR) Rationale: the action that the nurse should take is to draw a PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide info as to how to best treat this client. The aPTT measures the effects of heparin therapy. The nurse is caring for a post-op client who is receiving demand-dose hydromorphone by a PCA pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vitals: temp of 97.2, pulse 52 bpm, bp of 101/58, RR 11, and O2 93% on 3 liters of O2 via nasal cannula. Which action should the nurse take next?
9. Document the findings
10. attempt to arouse the client

3. contact the hc provider immediately
4. check the medication administration history on the PCA pump - correct answer 2. attempt to arouse the client Rationale: the primary concern with opioid analgesics is respiratory depression and hypoteterm-75nsion. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vitals. The vitals may begin to normalize once the client is aroused. The client should also check the PCA pump to see how much medication the client has taken and continue to monitor the client closely to determine if further action is needed. After all data is collected, after the client is stabilized, and if an abnormality still exists the nurse should contact the provider and document the findings. An adult female client has a hemoglobin level of 10.8g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history?
5. dehydration
6. HF
7. iron deficiency anemia
8. COPD - correct answer 3. iron deficiency anemia Rationale: the normal hemoglobin level for an adult female client is 12 to 16. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. HF and COPD may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. A client with a history of upper GI bleeding has a platelet count of 300,000. The nurse should take what action after seeing the lab result?
9. report the abnormally low count
10. report the abnormally high count
11. place the client on bleeding precautions
12. place the normal report in the client's medical record - correct answer 4. place the normal report in the client's medical record Rationale: a normal platelet count ranges from 150,000 to 400,000. The nurse should place the report with the normal lab value in the client's medical record, since a platelet level of 300,000 is not an elevated amount. Also since the count is not low, bleeding precautions are not needed. The nurse is teaching a client with iron deficiency anemia about foods she should include in her diet. the nurse determines she understands the teaching when she selects which items from the menu?
13. nuts and milk
14. coffee and tea
15. cooked rolled oats and fish
16. oranges and dark green leafy veggies - correct answer 4. oranges and dark green leafy veggies

Rationale: dark green leafy veggies are a good source of iron, and oranges have vitamin C which enhances iron absorption. The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. the nurse develops a list of high fat foods to avoid and should include which of the following items? select all that apply

1. oranges
2. broccoli
3. margarine
4. cream cheese
5. luncheon meats
6. broiled haddock - correct answer 3, 4, 5 Rationale: margarine, cream cheese, and luncheon meats are high-fat foods. the nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. the nurse determines the client understands these modifications if the client selects which items from the menu?
7. cream of wheat, blueberry, coffee
8. sausage and eggs, banana, orange juice
9. bacon, cantaloupe, tomato juice
10. cured pork, grits, strawberry, orange juice - correct answer 1. cream of wheat, blueberry, coffee Rationale: the diet for this client should include controlled amounts of sodium, phosphorous, calcium, potassium, and fluids. this is the only option that does not contain high amounts of these substances. the nurse is conducting a dietary assessment for a client who is vegan. the nurse provides dietary teaching and should focus on foods high in which vitamins that may be lacking in a vegan diet?
11. Vitamin A
12. vitamin B12
13. vitamin C
14. Vitamin E - correct answer 2. vitamin B12 Rationale: B12 comes from animal products and would likely be lacking in a vegan diet. A client with HTN has been told to maintain a diet low in sodium. the nurse who is teaching this client should include which food item in a list of allowed foods?
15. tomato soup
16. boiled shrimp
17. instant oatmeal
18. summer squash - correct answer 4. summer squash