NCLEX Practice Questions Test Bank New Latest Version Updated 2023-2024 with 200+ Querys, Exams of Nursing

Download NCLEX Practice Questions Test Bank New Latest Version Updated 2023-2024 with 200+ Querys and more Exams Nursing in PDF only on Docsity! NCLEX Practice Questions Test Bank New Latest Version Updated 2023-2024 with 200+ Questions and 100% Correct Answers The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? • Left foot is cool to the touch • Absent lef t pedal pulse using Doppler analysis • Inability to palpate the left pedal pulse • Acute pain in the left lower leg Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider. Ref # 1028 There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order. Ref # 1440 Which individual is at greatest risk for the development of hypertension? 45 year−old African−American attorney The incidence of hypertension is greater among African−Americans than other groups in the United States. The incidence among the Hispanic population is rising. Ref # 2446 A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Ask the client to stay on the line, get the address, and send an ambulance to the home requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure. Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? High fat, high−calorie CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high−energy diet that includes high−fat and high−calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten−free diet. Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Notify the health care provider Pain and absence of a pulse within 48−72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity. Ref # 1927 The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "Urinary output seems to be less over the past two days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse. Ref # 1370 A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Check complete blood count (CBC) with differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/μ Ref # 1773The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T−6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life− threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. Ref # 2144 A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority. Ref # 1740An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A middle−aged person with deep abrasions that are over 90% of the body The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are usually treated as second or third degree burns because the fluid loss is great. ref # 1750The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? Careful repositioning Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures. Ref # 2332 The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? It decreases serum phosphate Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate. Ref # 1771The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect? (Stephen hawkins) Shallow respirations ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch. Ref # 1625 A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take? Assess the chest tube dressing, tubing and drainage system The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in the water−seal chamber right after surgery indicates an air leak from the pleural space; this is a common finding and should resolve as the lung re−expands. Continuous bubbling usually means a leak in the CDU, such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and assessing the lungs. After the initial post−operative period, the nurse will assist the client to change positions and cough and deep breath to help re−expand the lung and promote fluid drainage. Ref # 1551Today's prothrombin time for a client receiving warfarin 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Recognize that this is a therapeutic level For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually 1 1/2 to 2 times the normal levels. Ref # 1599 The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize Avoid large and heavy meals Eating large, heavy meals can pull blood away from the heart for the digestion process. This may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the size of the meal, which is more important. Ref # 1749 The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority? Prepare the client for insertion of a new CVAD Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source of the infection, it should be cultured and removed. A new central line (usually an internal jugular or subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The new central line will also allow venous access for labs, medications and measuring central venous pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent infections to help protect all clients. Ref # 1525 The client is scheduled for coronary artery bypass. Based on principles of teaching and learning, what is the best initial approach by the nurse during pre-op teaching? Assess the client's learning style As with any anticipatory teaching, assessment of retention, and increased potassium loss. Dexamethasone also causes calcium loss; the client should increase calcium in the diet and take a calcium supplement. Because the medication affects the immune system, it could make vaccinations ineffective and/or lead to serious infections. It's always a good idea for clients to keep track of medication administration, particularly when they are not taking the medication every day. Ref # 2419 A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process? Fetal heart rate is 188 beats/minute Prolonged ruptured membranes may lead to maternal infection (as suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188; fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and administer oxygen and intravenous fluids. Ref # 2247 The registered nurse (RN) is planning the care of an 80-year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse? Perform a head−to−toe assessment The RN is responsible to conduct a thorough assessment and evaluation of all body systems for this client. The nurse would document information collected during the focused assessment, such as changes in skin color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility. Ref # 1650 A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching? "I will only have to wear this for six months." The brace must be worn long−term, during periods of growth, usually for one to two years. It is used to correct scoliosis, the lateral curvature of the spine. Ref # 1629 The nurse, who is participating in a community health fair, assesses the health status of attendees. When would the nurse conduct a mental status examination? As part of every health assessment A mental status assessment is a critical part of baseline information and should be a part of every examination. Ref # 1520 A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse? Papules, vesicles and crusts will be present at one time All three stages of the chickenpox lesions will be present on the child's body at the same time. Children should not be medicated with aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to two days before their blisters appear and remain contagious until all the blisters have crusted over. Antiviral medications are not usually prescribed to otherwise healthy children. Over−the−counter hydrocortisone creams can help relieve itchy skin Ref # 5280 During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client teaching? (Select all that apply.) "You should drink at least 8-10 glasses of water a day." "Yoga may help you manage stress and relieve symptoms." "Incorporate more vegetables and legumes in your diet." "Use deep breathing exercises when you start having a hot flash." Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6−8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant−based diet can also help. Ref # 1776 A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? The baby is post-term Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from −10 to 50. Premature babies have lower scores; higher scores correlate with post−maturity. Fetal distress during labor can result in lower scores. Ref # 5307 A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase meeting effectiveness? (Select all that apply.) "During our meeting today we will share the information we have on falls." "Let's discuss when next we should meet and what information we will bring." "Please introduce yourselves and your departments." "Let's focus on the number of falls first and then we can talk about staffing." A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members' other commitments. Ref # 1728 A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately? Serum potassium 6 mEq/L (6 mmol/L) Although all of these findings are abnormal, the elevated potassium level 3.5 to 5.0 is a life−threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life−threatening ventricular dysrhythmias. Anemia (hemoglobin less than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women) is common with kidney disease. Blood urea nitrogen (BUN) will be increased in acute renal failure (7 to 30 mg/dL [2.5 to 10.7 mmol/L] is a considered normal). Ref # 2290 A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings? Extremity tingling and numbness Peripheral neuropathy is a common side effect of isoniazid and other antitubercular medications and should be reported to the health care provider. Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use avoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the hip joint. This increases the risk of a malfunction of the prosthesis where the ball may pop out. A walker or crutches may be used as assistive devices. These and other precautions are minimally followed for six weeks postoperative and sometimes longer as indicated. Ref # 4511Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? Bring the communication focus back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. Ref # 2258The charge nurse is making assignments for the shift. Which of these clients would be appropriate to assign to a licensed practical nurse (LPN)? An older adult client diagnosed with cystitis and has an indwelling urethral catheter most stable client is the one diagnosed with cystitis. Care for this client has predictable outcomes and there is only a minimal risk for complications. The other clients require more complex care and independent, specialized nursing knowledge, skill or judgment that only an RN can provide. Ref # 1529A nurse is teaching a class on human immunodeficiency virus (HIV) prevention. Which activity should be cautioned against since it is shown to increase the risk of HIV Engaging in unprotected sexual encounters HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks Ref # 1557 A young adult seeks treatment in an outpatient mental health center. The client tells the nurse: "I am a government official being followed by spies." On further questioning, the client reveals: "My warnings must be heeded to prevent nuclear war." Which of the following actions should the nurse take? Listen quietly without comment demonstrate grandiose ideas. The most therapeutic response is to listen but to also avoid being pulled into the client's delusional system. At some point validation of the present situation will need to be done. Confrontation at this time would be an inappropriate action and is not therapeutic Ref # 2213 Following an alert of an internal disaster and the need for beds, the charge nurse is asked to list the clients who can potentially be discharged. Which one of these clients should the charge nurse select? An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis type 1 diabetes is the only one with a chronic condition who has been treated for more than a day and whose condition is the most stable ef # 2025 Nursing students are reviewing the various types of oxygen delivery systems. Which oxygen delivery system is the most accurate? The Venturi mask The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55% Ref # 1864 A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement? "You have been exposed to the organism Mycobacterium tuberculosis." the PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x−ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB. Ref # 2016 A pregnant client, at 34-weeks gestation, is diagnosed with a pulmonary embolism (PE). Which of these medications does the nurse anticipate the health care provider will initially order? Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value intravenous unfractionated heparin (UFH). The client's activated partial thromboplastic time (aPTT) should be monitored and kept in the therapeutic range of between 1.5 to 2 times the baseline value. Alternatively, low molecular weight heparins, such as enoxaparin (Lovenox), can be used to treat PE in women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects Ref # 2445 At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first? An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum The 18 year−old client has an actual complication of left−sided heart failure and a possible stillborn birth. The other clients present with findings of potential, but not actual, complications. Ref # 1676 the nurse is preparing to administer albuterol inhaled to a 11 year-old with asthma. Which assessment by the nurse indicates there is a need for the health care provider to adjust the medication? Apical pulse of 112 common adverse effects of beta adrenergic medications such as albuterol (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA), is an increase in heart rate. Normal resting heart rate for children 10 years and older is the same as adults: 60−100 beats per minute Ref # 1920 A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority? Apply waterproof plastic tape to the cast around the genital area keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer (set to cool) may be used to help dry the cast. Ref # 1530 A nurse is teaching adolescents about sexually transmitted diseases. What should the nurse emphasize is the most common infection? Ref # 1847 The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure?Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes. Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical reactions in the blood. ef # 1250 A client has just received an extracorporeal shock-wave lithotripsy (ESWL) procedure. What is the priority information the nurse should teach ? "Drink 3,000 to 4,000 mL of fluid each day for one month." Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi. Ref # 1553 A client has received two units of whole blood today after an episode of gastrointestinal bleeding. Which laboratory report should the nurse be sure to monitor closely? Hemoglobin and hematocrit The post−transfusion hematocrit provides immediate information about red cell replacement and if there is any continued blood loss; the follow− up hematocrit should be checked around 4 to 6 hours after the infusion is completed. ef # 1992 A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown? Ileostomy which is from the small intestine, is of continuous, liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on skin can denude skin in a few hours. Ref # 1653 The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best comment by the nurse should include which point? Chlamydia effects of their behavior on the person who was battered. Batterers use excessive minimization and denial of the situation and their behaviors or intent. Ref # 2234 A newly admitted 78 year-old client is diagnosed with severe dehydration. When planning care for this client, the nurse should assign which task to an unlicensed assistive personnel (UAP)? Report hourly outputs of less than 30 mL/hr within 15 minutes of the check the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the RN is responsible for all care−related decisions, only routine tasks should be assigned to UAPs because such tasks do not require judgments and decisions. Ref # 1991At a senior citizen's group meeting the nurse talks with a client who has type 1 diabetes. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairmen Ref # 2454 The clients listed below are all using patient-controlled analgesic (PCA) pump for pain control. Which of these clients is least appropriate to use a PCA pump A preschooler with intermittent episodes of alertness A preschooler is the one client most likely to have difficulty with the use or understanding of a PCA pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School−age children, ages 6 and up, are better candidates for PCA electronic pumps. Ref # 1969 The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of these statements is the best advice about sun protection for this child? "Dress the infant in lightweight long pants, long−sleeved shirts and brimmed hats." Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned while near water. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands). Ref # 1817 A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a nearby chair. The mother states, "This is not my baby, and I do not want it." After repositioning the child safely, the nurse should respond with which comment? "You seem upset. Tell me what the pregnancy and birth were like for you." A nonjudgmental, open ended response facilitates dialogue between the client and the nurse. The other three options ignore the situation and the needs of the mother. Note that the correct answer is the only client-centered option that is directly associated with the given situation. Ref # 4509 The nurse, who is located in a large urban area, uses telecommunications to provide health care and education to clients in remote locations. What is the best reason for using telehealth? Removes time and distance barriers from the delivery of care Telehealth is the use of technology to deliver health care, health information, or health education at a distance. People in rural areas or homebound clients can communicate with providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care. Although increased access to information and collaboration between the client and provider can be empowering, this is not the primary reason for using telecommunications/telehealth. Ref # 2233 The health care team consists of one licensed practical nurse (LPN), one unlicensed assistive person (UAP) and one LPN student. The charge nurse (an RN) has made the following assignments. Which assignment should be questioned by the nurse manager? The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure − LPN LPNs can provide care for clients whose conditions are stable and there's a low likelihood of an emergency. Since it's a new admission, the client diagnosed with atrial fibrillation and heart failure should not be assigned to a student; the charge nurse (RN) should care for this client. A nurse can assign tasks or activities to UAP, as long as the care of the client is not too complex or variable and the client's condition is stable. Ref # 1255 During a situation of pain management, which statement is a priority to consider for the ethical guidance of a nurse The client's self−report is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it Is Ref # 1879 Which statement describes the advantage of using a decision grid to make decisions? It is both a visual and a quantitative method of decision making A decision grid allows the group to visually examine alternatives and evaluate them quantitatively with weighting. Ref # 1976 An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. What should the nurse understand about the child's situation and administration of the immunization? The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant MMR is a live virus vaccine, and should be given at this time. Post−transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. Ref # 1241 A client is started on long-term corticosteroid therapy. Which comment by the client indicates a need for more teaching? "For one week every month I will stop taking the medication." To suddenly stop taking a steroid may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium−rich foods. Weight gain is an expected effect of corticosteroid therapy; clients should regularly keep track of their weight. Normally corticosteroid medications are taken with breakfast. Ref # 2254 The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse assign to the unlicensed assistive person (UAP)? Test stool for occult blood and urine for pH and report the results UAP can perform routine tasks that have known or expected outcomes because these tasks typically do not require nursing judgment or decision− making. Any nursing intervention that requires independent, specialize nursing knowledge, skill or judgment cannot be assigned to UAP. Ref # 1374 The parents of a 5 month-old report that the infant has "vomited nine times in the past six hours." Based on this information, the nurse should observe for which fluid and electrolyte imbalance? Metabolic alkalosis Vomiting results in a loss of acid from the stomach. Prolonged vomiting results in excess loss of acid and leads to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Hemoconcentration due to fluid loss may occur, but is not the best answer because it does not answer the question about an imbalance. Ref # 1626 A client who is two days postop, has these vital signs: blood pressure of 120/70, heart rate of 110 BPM, respiratory rate of 26, and a temperature of 100.4 F (38 C). The client suddenly becomes profoundly short of breath (SOB) and the skin color becomes grayish in color. Which assessment should the a nurse do first based on the client's change in condition? Auscultate for diminished breath sounds The findings suggest pulmonary embolus as a result of a piece of a clot in the legs that has broken off. Thus, the breath sound will most likely be diminished or absent in the lung where the embolus lodged. Ref # 1494 The nurse is caring for a child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The nursing care plan should be based on the knowledge that this child is at risk for developing what complication? Coronary artery aneurysm Kawasaki disease affects the mucus membranes, lymph nodes, walls of the blood vessels and the heart. It can cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to aneurysms and possible heart attack in the child. Ref # 1592 The nurse is caring for a client who is experiencing a hypertensive crisis. The priority assessment in the first hour of care after admission to the history. What information would the nurse recognize as a contraindication for giving the child this vaccine? Allergy to eggs An allergy to egg proteins is listed by the CDC as a contraindication for administering the influenza vaccine. Influenza vaccines are grown on egg embryos and may contain a small amount of egg protein. Ref # 2089 Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse anticipates their reaction to be in which phase of the crisis process? Impact phase impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inability to apply problem−solving behavior. Ref # 1966A nurse is providing a parenting class to individuals living in a community of older homes that were built prior to 1978. During a discussion about formula preparation, which statement is the most important by the nurse to tell the parents how to prevent lead poisoning? Let tap water run for two minutes before adding to formula concentrate Ref # 4320The order is for ibuprofen oral drops 10 mg/kg of body weight. The client weighs 62 lbs. Motrin oral drops are supplied in bottles containing 40 mg/mL. How many milliliters will the nurse administer? (Report to the nearest whole number. Dimensional analysis: X mL = 1 mL/40 mg X 10 mg/kg X 1 kg/2.2 lbs X 62 lbs = 620/88 = 7.05 or 7 mL Ratio : 62 lbs/x = 1 kg/2.2 lbs = 28.19 kg 10 mg/x = 1 mL/40 mg = 10/40 = 0.25 0.25 X 28.19 = 7.05 or 7 Ml Ref # 1567 The nurse observes a client with a diagnosis of obsessive-compulsive disorder on an inpatient unit. Which behavior is consistent with this medical diagnosis Repeatedly checking that a door is locked Obsessive−compulsive disorder is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions.) People know their thoughts and behaviors don't make sense, but they are often unable to stop them. Verbalized suspicions reflect a paranoid thought process. Repetitive, involuntary movements are characteristic of some antipsychotic medication side effects. Ref # 1297 As a client is being discharged following resolution of a spontaneous pneumothorax, the client tells a nurse, "I'm going to Hawaii for a vacation next week." The nurse should warn the client to avoid which activity? Scuba diving avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressure associated with diving could cause the lung to collapse again. Ref # 1523 The nurse is teaching effective stress management techniques to a client one hour before surgery. Which of these actions should the nurse recommend? Deep breathing Deep breathing is a reliable and valid method for stress reduction and can be taught and reinforced in a short period of time preoperatively. The other approaches require more time and repetition over time Ref # 1296 The nurse is assigned to a client newly diagnosed with active tuberculosis (TB) and a productive cough. Which of these interventions would be a priority for the nurse to implement? Place the client in a negative pressure private room and have disposable particulate respirators available for hospital employee The client would be placed on airborne precautions because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents. Any hospital employee entering the room would need to wear a disposable micron mask or disposable particulate respirator (N−95, for example). The Centers for Disease Control and Prevention (CDC) state that visitors can wear surgical masks Ref # 2338 The nursing team listens to a change-of-shift report and then the RN determines that the unlicensed assistive person (UAP) can measure vital signs for all clients except the 80-year-old female diagnosed with middle-stage Alzheimer's disease. What information mentioned in the report suggests the registered nurse should personally follow up and assess the client with Alzheimer's disease? Increased confusion, agitation and withdrawal Ref # 1418 The nurse and family members, who will be providing care at home, are discussing the client's continuing care needs after discharge to home. Which of these aspects of the discharge planning evaluation should receive priority consideration? Family's understanding of the client's health care needs Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. Ref # 2135 A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis prior to discharge. What information would the nurse want to include when helping the client better understand this type of cancer? Testicular cancer has a five−year survival rate of 95% with early diagnosis and treatment With aggressive treatment and early detection/diagnosis the cure rate is 90%. The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely. In bilateral orchiectomy, fertility is lost, so sperm banking prior to surgery is recommended. Dissection of lymph nodes for surgical cancer treatment may cause nerve injury, which would increase the risk of impotence. Ref # 1737 During the change-of-shift report, the assigned nurse notes a client of the Catholic religion is scheduled to be admitted for the delivery of a ninth child. Which comment made by a nurse indicates an attitude of prejudice? "All those people indulge in large families!" Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. Ref # 4348 The client is a new admission diagnosed with Alzheimer's disease (AD). The nurse reviews all drugs (including complementary & integrated health therapies) routinely taken at home with a family member. Which of the following treatments would be a concern for the nurse? Coconut oil no scientific evidence that coconut oil is safe and effective or prevents cognitive decline. Ref # 1495 The nurse is providing discharge teaching to the parents of a 15 month- old child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The child has received immunoglobulin therapy. Which instruction point would be appropriate to include during the discussion? The measles, mumps and rubella vaccine should be delayed he MMR vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment. Ref # 1266 A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action the nurse should take? Suction excessive tracheobronchial secretions This type of surgery involves removing a bronchovascular segment of a lobe. It is typically used to remove small, peripheral lung tumors. Surgical manipulation during this procedure, along with anesthesia, can increase mucus production and lead to airway obstruction, which is why the nurse may need to suction the client if there are excessive secretions Ref # 1802 A nurse is teaching an older adult client to use a metered-dose inhaler (MDI) and is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What should the nurse recommend to improve the delivery of the medication? Add a spacer device to the MDI canister Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye− hand coordination. If the client is not using the MDI properly, the medication can get trapped in the alcohol and stress management, these changed behaviors suggest that learning has occurred. Additionally, physical assessments, observed behaviors and lab data may confirm risk reduction. Ref # 1235 The client, diagnosed with an acute anterior MI, has a triple lumen infusing with nitroglycerin, alteplase and heparin. The client reports experiencing angina. Which intervention is the priority? Administer intravenous morphine sulfate as ordered Nitrates are useful for pain control due to their coronary vasodilating effects. The nurse will titrate the intravenous nitroglycerin infusion for chest pain according to standing orders but if chest pain is unrelieved by the nitroglycerin infusion, the nurse can administer morphine intravenously (IM injections are avoided because they can alter the CPK.) Morphine not only relieves pain and reduces anxiety, but also dilates blood vessels. After giving the pain reliever, the nurse can do a more in−depth assessment of the client (auscultate heart and lung sounds, review ECGs, vital signs and labs.) There is no need to administer an antidysrhythmic drug if the client is asymptomatic. Ref # 2252 An RN from a woman's wellness health clinic is temporarily reassigned to an adult medical unit. Which of these client assignments would be appropriate for this nurse? A client from a motor vehicle accident with an external fixation device on the leg The nurse from the wellness clinic should be assigned to the client with the leg fracture. This client is the most stable and providing care for this client has predictable outcomes. The clues in the other options are: "newly diagnosed," "after a TIA," and "newly admitted... severe dehydration" − all of these clients have an health condition that's less stable than the client who is basically healthy (except for a fracture from an accident). Ref # 1848 A client is about to have an intravenous pyelogram (IVP). After the contrast material is injected, which client reaction should be acted upon immediately by a nurse? Hives with severe itching over the body Hives over the body with severe itching is a sign of anaphylaxis and should be acted upon with the administration of epinephrine (adrenaline) immediately. The other reactions are considered normal after the dye injection. Prior to any dye injection procedure clients should be informed that these symptoms may occur. Excessive salty taste in the mouth, Face turning a deep ruddy red color, Feeling of excessive warmth Ref # 1321 The nurse receives a report on a client being admitted with the diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the nursing assistant about providing care for this client? The client should ambulate as tolerated, resting in bed with legs elevated between walks Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client to gradually increase the duration and frequency of walks. Ref # 2461 A 35 year-old female client talks to the nurse in her health care provider's office about her new diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more teaching is needed? "Even if the fibroids cause no problems, they will still need to be taken out." Fibroids that cause no findings may require only "watchful waiting." The client may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth. Treatment for the symptoms of fibroids (such as painful menses and heavy periods) may include oral contraceptives, IUDs, iron supplements to prevent or treat anemia (due to heavy periods), NSAIDs for cramps or pain or even short−term hormonal therapy to help shrink the fibroids. Surgical removal using myomectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. In addition, concerns about loss of fertility with this diagnosis and its treatment may be important to this client who is still in her childbearing years. Ref # 5270 The nurse is providing care for a school-age child with cerebral palsy who has recently been admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion with the child's caregivers, which statement by the nurse best demonstrates client advocacy? "It is possible that we may need to discuss inserting a feeding tube." Ref # 2037A woman in labor calls a nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse should act based on knowledge that fetal monitoring must now assess for what complication? Variable decelerations When the membranes rupture, there is increased risk initially of cord prolapse if the head is at a minus level. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to reposition the client, apply oxygen and notify the health care provider. Ref # 1973 The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is 103 F (39.4 C). Which intervention would be most effective in lowering the client's temperature and promoting comfort? Administer the prescribed antipyretic medication Ref # 4420 The 72 year-old client has an estimated blood loss of 600 mL during a gastric resection. The surgeon orders two units of packed cells (PC) to be administered in the post anesthesia care unit. During the administration of the second unit of PC, the nurse notes the following findings: hypertension, a bounding pulse, and increasing dyspnea. What is the probable cause of these findings? Circulatory overload Older clients are at risk for circulatory overload, especially when solutions are administered rapidly. Hypertension with a bounding pulse and dyspnea are key signs of fluid overload. The nurse should stop the infusion and contact the health care provider Ref # 4416 Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) Check for appropriate fit Confirm pressure setting of 45 mm Hg Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Ref # 1825 The parents of a 6 year-old child who normally enjoys school tells a nurse that the child has not been doing well since a grandmother died two months ago. Which statement most accurately describes thoughts on death and dying at this age? Death is personified as the bogeyman or devil Personification of death is typical of this developmental level. Recall that this age is at the end of the preschool period where magical thinking for the animation of inanimate objects is present. Ref # 2450 An internal disaster has occurred at the hospital. The charge nurse is asked to review client acuity and determine which clients can and cannot be discharged. Which of these clients should not be discharged? young adult in the second day of treatment for an overdose of acetaminophen An overdose of acetaminophen requires close observation for several days. Also, the duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately 72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion, least stable Ref # 1761A nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis (TB). Which of these instructions should be given to the client? Continue taking medications as prescribed Early cessation of treatment may lead to development of drug resistant TB. Active TB is usually treated with a combination of four different antibiotics (isoniazid, rifampin, ethambutol and pyrazinamide) and can take anywhere from 6 to 12 months to completely kill the bacteria Ref # 1812 The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? Ref # 1812The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? The ethical sense and feelings of justice are developing developing a sense of justice and a desire to do what is right. At 7, children are increasingly