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A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts ondeath and dying at this age?A) Death is personified as the bogeyman or devilB) Death is perceived as being irreversibleC) The child feels guilty for the grandmother’s deathD) The child is worried that he, too, might die A
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are presentA) Temperature of 37.5 degrees Celsius with painful urinationB) An open wound on their heelC) Insomnia and daytime fatigueD) Nausea with 2 episodes of vomiting B
The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initiallyA) Request a Spanish interpreterB) Speak through the family or co-workersC) Use pictures, letter boards, or monitoring D) Assess the client’s ability to speak English D
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?A) Uterine atonyB) Genital lacerations C) Retained placentaD) Clotting disorder B
The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?A) AnticoagulantB) Liquid antacidC) AntihistamineD) Cardiac glycoside C
The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?A) Instruct the client to wear a high efficiency particulate air mask in public places.B) Ask a family member to supervise daily complianceC) Schedule weekly clinic visits for the clientD) Ask the health care provider to change the regimen to fewer medications B
“The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that “”staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting.”” The nurse manager’s leadership style is best described asA) Laissez-faire B) Autocratic C) Participative D) Group” C
A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should includeA) The escalation of fees with a decreased reimbursement percentageB) High costs of diagnostic and end-of-life treatment proceduresC) Increased numbers of elderly and of the chronically ill of all ages D) A steep rise in health care provider fees and in insurance premiums A
A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client?A) Wear masks with shields if potential splashB) Use disposable utensils and plates for mealsC) Wear gown and gloves during client contactD) Provide soft easily digested food with frequent snacks C
A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug?A) Tranquilization, numbing of emotionsB) Sedation, analgesiaC) Relief of insomnia and phobiasD) Diminished tachycardia and tremors associated with anxiety A
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member isA) Advising client to restrict sodium intakeB) Taking the blood pressure in the left armC) Elevating her left arm above heart levelD) Compressing the drainage device B
A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:A) Impaired gas exchangeB) Metabolic acidosisC) Renal insufficiencyD) Fluid volume deficit D
“The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client statedA) “”I can only wear cotton socks.””B) “”I cannot go barefoot around my house.””C) “”I will trim corns and calluses regularly.””D) “”I should ask a family member to inspect my feet daily.””” C
“A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states “” I have had the worst headache for the past 2 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?A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her health care provider within the next day.B) Advise the client to have someone bring her to the emergency room as soon as possibleC) Ask the client to stay on the line, get the address and send an ambulance to the home D) Ask what the client has taken? How often? Ask about other specific complaints.” C
The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure isA) Drink 3000 to 4000 cc of fluid each day for one monthB) Limit fluid intake to 1000 cc each day for one monthC) Increase intake of citrus fruits to three servings per day D) Restrict milk and dairy products for one month A
A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?A) Avoid Alka-Seltzer because it contains aspirinB) Take Alka-Seltzer at a different time of day than the warfarin C) Select another antacid that does not inactivate warfarinD) Use on-half the recommended dose of Alka-Seltzer A
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be toA) Encourage the parents to enroll in cardiopulmonary resuscitation classB) Assist the parents to plan quiet play activities at homeC) Stress to the parents that they will need relief care giversD) Instruct the parents to avoid contact with persons with infection A
The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?A) Risk for injuryB) Self care deficitC) Alteration in comfort D) Alteration in mobility C
“An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?A) “”Spiritual healing is emphasized and the mind contributes to the cure.””B) “”The primary belief is that dietary practices result in health or illness.”” C) “”Fasting and prayer are initial actions to take in physical injury.””D) “”Meditation is intensive in the initial 48 hours and daily thereafter.””” A
In order to be effective in administering cardiopulmonary resuscitation to a 5 year- old, the nurse mustA) Assess the brachial pulsesB) Breathe once every 5 compressionsC) Use both hands to apply chest pressureD) Compress 80-90 times per minute B
The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?A) Impaired skin integrity related to dependent edemaB) Activity intolerance related to oxygen supply and demand imbalanceC) Constipation related to immobilityD) Risk for infection related to ineffective mobilization of secretions B
For which of the following mother-baby pairs should the nurse review the Coomb’s test in preparation for administering RhO (D) immune globulin within 72 hours of birth? A) Rh negative mother with Rh positive babyB) Rh negative mother with Rh negative babyC) Rh positive mother with Rh positive baby D) Rh positive mother with Rh negative baby A
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?A) Lung soundsB) Urine outputC) Level of alertness D) Appetite C
What is the major purpose of community health research? A) Describe the health conditions of populationsB) Evaluate illness in the communityC) Explain the health conditions of familiesD) Identify the health conditions of the environment A
The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor?A) The increased homeless population in major citiesB) The rise in reported cases of positive HIV infectionsC) The migration patterns of people from foreign countries D) The aging of the population located in group homes B
A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?A) MMR B) Hib C) IPVD) DtaP A
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?A) Sexually transmitted infectionB) Exposure to teratogensC) Maternal hypertensionD) Chromosomal abnormalities C
After the shift report in a labor and delivery unit which of these clients would the nurse check first?A) A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94 B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated C) A young woman is a grand multipara has cervical dilation of 4 cm and 50% effaced D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum D
The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?A) Fecal impactionB) Infrequent voidingC) Stress incontinenceD) Burning with urination A
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse shouldA) Irrigate it as ordered with distilled waterB) Irrigate it as ordered with normal salineC) Place the end of the tube in water to see if the water bubbles D) Withdraw the tube several inches and reposition it B
“The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is “”Asthma causes… A) the airway to become narrow and obstructs airflow.””B) air to be trapped in the lungs because the airways are dilated.””C) the nerves that control respiration to become hyperactive.””D) a decrease in the stress hormones which prevents the airways from opening.””” A
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?A) Complaints of numbness and tingling in feetB) Wheezing noted when lung sound auscultatedC) Excessive perspiration D) Difficulty sleeping A
The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client’s impending death. What action should the nurse do first?A) Explain the stages of death and dying to the familyB) Recommend an easy-to-read book on griefC) Assess the family’s patterns for dealing with death D) Ask about their religious affiliations C
The nurse is caring for a client with Meniere’s disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high inA) CalciumB) FiberC) SodiumD) Carbohydrate C
The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority?A) Show her films on the physiology of lactationB) Give the client several illustrated pamphletsC) Assist her to position the newborn at the breastD) Give her privacy for the initial feeding C
The nurse is taking a health history from parents of a child admitted with possible Reye’s Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye’s Syndrome?A) RubeolaB) MeningitisC) VaricellaD) Hepatitis C
“While giving care to a 2 year-old client, the nurse should remember that the toddler’s tendency to say “”no”” to almost everything is an indication of what psychosocial skill?A) Stubborn behaviorB) Rejection of parentsC) Frustration with adultsD) Assertion of control” D
A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome?A) Growth retardation is evidentB) Multiple anomalies are identifiedC) Cranial facial abnormalities are noted D) Prune belly syndrome is suspected C
The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis?A) The number of persons in a population who develop Hepatitis B during a specific period of timeB) The total number of persons in a population who have Hepatitis B at a particular timeC) The percentage of deaths resulting from Hepatitis B during a specific timeD) The occurrence of Hepatitis B in the population at a particular time A
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?A) Capillary refill less than 3 secondsB) Pale mucous membranesC) Respirations 36 breaths per minuteD) Complaints of fatigue when ambulating A
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?A) Tuberculin skin testing B) Sputum cultureC) White blood cell count D) Chest x-ray B
The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?A) The mother feels calmer and talks to the baby while nursingB) The mother awakens the newborn to feed whenever it falls asleep C) The newborn falls asleep after 3 minutes at the breastD) The newborn refuses the supplemental bottle of glucose water A
“The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse isA) “”The top layer of the skin is destroyed.””B) “”The skin layers are swollen and reddened.””C) “”All layers of the skin were destroyed in the burn.”” D) “”Muscle, tissue and bone have been injured.””” C
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is consideredA) Expected B) RudeC) Professional D) Enjoyable B
A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child?A) Riding in a carB) Falling off a bedC) Electrical outletsD) Eating peanuts D
When teaching parents about sickle cell disease, the nurse should tell them that their child’s anemia is caused byA) Reduced oxygen capacity of cells due to lack of ironB) An imbalance between red cell destruction and productionC) Depression of red and white cells and platelets D) Inability of sickle shaped cells to regenerate B
The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe?A) Hypertonic neuro reflexB) Immediate CNS depressionC) Lethargy and sleepiness D) Jitteriness at 24-48 hours D
The nurse is caring for a client with congestive heart failure. Which finding requires the nurse’s immediate attention?A) Pulse oximetry of 85% B) NocturiaC) Crackles in lungsD) Diaphoresis A
The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?A) Inspect the skinB) Auscultate breath soundsC) Evaluate muscle strengthD) Investigate elimination patterns A
Which action is most likely to ensure the safety of the nurse while making a home visit?A) Observation during the visit of no evidence of weapons in the homeB) Prior to the visit, review client’s record for any previous entries about violenceC) Remain alert at all times and leave if cues suggest the home is not safe D) Carry a cell phone, pager and/or hand held alarm for emergencies C
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused byA) TachypneaB) Acidic byproductsC) Vomiting and dehydrationD) Hyperpyrexia A
“The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “”We are concerned about the possible occurrence of sudden infant deathsyndrome (SIDS).”” In order to take appropriate action, the nurse must understand that A) The child is within the age group most susceptible to SIDSB) The peak age for occurrence of SIDS is 8 to 12 months of ageC) The apnea monitor is not effective on a child in this age groupD) 95% of SIDS cases occur before 6 months of age” D
As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoidA) SurfingB) Scuba divingC) ParasailingD) Swimming B
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should beA) High calorie, low fat, low sodiumB) High protein, low fat, low carbohydrateC) High protein, high calorie, unrestricted fatD) High carbohydrate, low protein, moderate fat C
“A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a “”feeling of being hot all the time.”” The nurse should assign the client to share a room with a client with the diagnosis ofA) Acute tuberculosis with a productive cough of discolored sputum for over three monthsB) Lupus and vesicles on one side of the middle trunk from the back to the abdomen C) Pseudomembranous colitis and C. difficile.D) Exacerbation of polyarthritis with severe pain” A
A client’s admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?A) Moist mucous membranesB) Urinary frequencyC) Poor skin turgorD) Increased blood pressure C
Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach? A) Consider a liquid supplement to increase caloriesB) Discuss consequences of an unbalanced diet with the child C) Provide fruit, vegetable and protein snacksD) Encourage the child to keep a daily log of foods eaten B
“At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “”My blood pressure is usually much lower.”” The nurse should tell the client toA) go get a blood pressure check within the next 48 to 72 hoursB) check blood pressure again in 2 monthsC) see the health care provider immediatelyD) visit the health care provider within 1 week for a BP check” A
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client isA) Maintain fluid and electrolyte balanceB) Control nauseaC) Manage painD) Prevent urinary tract infection C
“An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?A) A middle-aged client who says “”I took too many diet pills”” and “”my heart feels like it is racing out of my chest.””B) A young adult who says “”I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?””C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10D) An elderly client who reports having taken a “”large crack hit”” 10 minutes prior to walking into the emergency room” C
“While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?A) “”I want to protect my child from any falls.””B) “”I will set limits on exploring the house.””C) “”I understand the need to use those new skills.””D) “”I intend to keep control over our child.””” C
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?A) Gravida 4 para 2 B) Gravida 2 para 1C) Gravida 3 para 1 D) Gravida 3 para 2 C
A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?A) Gastric lavage PRNB) Acetylcysteine (mucomyst) for age per pharmacyC) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy A
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse isA) Verify correct placement of the tubeB) Check that the feeding solution matches the dietary orderC) Aspirate abdominal contents to determine the amount of last feeding remaining in stomachD) Ensure that feeding solution is at room temperature A
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be toA) Achieve harmonyB) Maintain a balance of energyC) Respect lifeD) Restore yin and yang D
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?A) angina at restB) thrombus formationC) dizzinessD) falling blood pressure B
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?A) The musclesB) The cerebellumC) The kidneysD) The leg bones A
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) TrichomoniasisB) ChlamydiaC) StaphylococcusD) Streptococcus B
During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten.B) We go to a group discussion every week at our community center.C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day. C
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?A) Apply dressing using sterile techniqueB) Improve the client’s nutrition statusC) Initiate limb compression therapy D) Begin proteolytic debridement B
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client toA) Increase fluids that are high in proteinB) Restrict fluidsC) Force fluids and reassess blood pressureD) Limit fluids to non-caffeine beverages C
Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorneyB) 60 year-old Asian American shop ownerC) 40 year-old Caucasian nurseD) 55 year-old Hispanic teacher A
“The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?A) Narrowed QRS complex B) Shortened “”PR”” interval C) Tall peaked T wavesD) Prominent “”U”” waves” C
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?A) Weight gain of 5 pounds B) Edema of the anklesC) Gastric irritabilityD) Decreased appetite D
Which of these statements best describes the characteristic of an effective reward- feedback system?A) Specific feedback is given as close to the event as possibleB) Staff are given feedback in equal amounts over timeC) Positive statements are to precede a negative statementD) Performance goals should be higher than what is attainable A
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due toA) Excessive fetal weightB) Low blood sugar levelsC) Depletion of subcutaneous fatD) Progressive placental insufficiency D
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?A) Positive sweat test B) Bulky greasy stoolsC) Moist, productive coughD) Meconium ileus C
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?A) Client must be NPO before the examinationB) Enema to be administered prior to the examinationC) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination D
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days agoB) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours agoC) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens- Johnson syndrome that morningD) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago A
A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with cryingB) A teenager who got a singed beard while campingC) An elderly client with complaints of frequent liquid brown colored stoolsD) A middle aged client with intermittent pain behind the right scapula B
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?A) Blood pressure 94/60 B) Heart rate 76C) Urine output 50 ml/hour D) Respiratory rate 16 A
A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take isA) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airwayD) Obtain the crash cart C
A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?A) Prepare the child for x-ray of upper airwaysB) Examine the child’s throatC) Collect a sputum specimenD) Notify the healthcare provider of the child’s status D
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre- operative client. Which action should the nurse take first?A) Raise the side rails on the bedB) Place the call bell within reachC) Instruct the client to remain in bed D) Have the client empty bladder D
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?A) PolyphagiaB) Dehydration C) Bed wetting D) Weight loss C
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:A) Should be taken in the morningB) May decrease the client’s energy levelC) Must be stored in a dark container D) Will decrease the client’s heart rate A
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measureA) Right heart functionB) Left heart functionC) Renal tubule function D) Carotid artery function B
“Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?A) The client complains of discomfort at the IV insertion siteB) The client states “”I just can’t get relief from my pain.””C) The level of drug is 100 ml at 8 AM and is 80 ml at noonD) The level of the drug is 100 ml at 8 AM and is 50 ml at noon” C
The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?A) Decrease in level of consciousnessB) Loss of bladder controlC) Altered sensation to stimuli D) Emotional lability A
When teaching a client with coronary artery disease about nutrition, the nurse should emphasizeA) Eating 3 balanced meals a dayB) Adding complex carbohydratesC) Avoiding very heavy mealsD) Limiting sodium to 7 gms per day C
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?A) Electrical energy fieldsB) Spinal column manipulation C) Mind-body balanceD) Exercise of joints B
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse shouldA) Place a call to the client’s health care provider for instructionsB) Send him to the emergency room for evaluationC) Reassure the client’s wife that the symptoms are transientD) Instruct the client’s wife to call the doctor if his symptoms become worse B
While assessing a 1 month-old infant, which finding should the nurse report immediately?A) Abdominal respirationsB) Irregular breathing rateC) Inspiratory gruntD) Increased heart rate with crying C
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities whichA) Increase the heart rateB) Lead to dehydrationC) Are considered aerobicD) May be competitive B
“The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?A) I have bad muscle spasms in my lower leg of the affected extremity.B) “”I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.””C) “”I have to use the bedpan to pass my water at least every 1 to 2 hours.””D) “”It seems that the pain medication is not working as well today.””” B
“The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?A) “”You need to regain your strength before attempting such exertion.””B) “”When you can climb 2 flights of stairs without problems, it is generally safe.””C) “”Have a glass of wine to relax you, then you can try to have sex.””D) “”If you can maintain an active walking program, you will have less risk.””” B
What would the nurse expect to see while assessing the growth of children during their school age years?A) Decreasing amounts of body fat and muscle massB) Little change in body appearance from year to yearC) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year D
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding , the nurse should plan toA) Restrict visitors to immediate familyB) Avoid arousal of the client except for family visitsC) Keep client’s hips flexed at no less than 90 degreesD) Apply a warming blanket for temperatures of 98 degrees Fahrenheit or less A
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score?A) Birth weightB) Racial differencesC) Fetal distress in laborD) Birth trauma C
A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?A) Place the child in the nearest bedB) Administer IV medication to slow down the seizureC) Place a padded tongue blade in the child’s mouthD) Remove the child’s toys from the immediate area D
A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that remediesA) Destroy organisms causing diseaseB) Maintain fluid balanceC) Boost the immune systemD) Increase bodily energy C
The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?A) NeurotoxicityB) HepatomegalyC) Nephrotoxicity D) Ototoxicity C
The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?A) Using a moist soft brush or cloth to clean teeth and gumsB) Swabbing teeth and gums with flavored mouthwashC) Offering a bottle of water for the child to drink D) Brushing with toothpaste and flossing each tooth A
“At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?A) “”I give my insulin to myself in my thighs.””B) “”Sometimes when I put my shoes on I don’t know where my toes are.””C) “”Here are my up and down glucose readings that I wrote on my calendar.”” D) “”If I bathe more than once a week my skin feels too dry.””” B
A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?A) Days 7-10B) Days 10-13C) Days 14-16D) Days 17-19 D
Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?A) Liver functionB) Kidney function C) Blood sugarD) Cardiac enzymes A
A 78 year-old client with pneumonia has a productive cough but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?A) Suction the client frequently while restrainedB) Secure all 4 restraints to 1 side of bedC) Obtain a sitter for the client while restrainedD) Request an order for a cough suppressant C
A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?A) Check the skin on the sacrum for breakdownB) Inspect the pin site for signs of infectionC) Auscultate the lungs for atelectasisD) Perform a neurovascular check for circulation D
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?A) Bounding pulseB) Rapid respirationsC) OliguriaD) Neck veins are distended C
When suctioning a client’s tracheostomy, the nurse should instill saline in order to A) Decrease the client’s discomfortB) Reduce viscosity of secretionsC) Prevent client aspirationD) Remove a mucus plug D
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?A) Drink small amounts of liquids frequentlyB) Eat the evening meal just before retiringC) Take sodium bicarbonate after each meal D) Sleep with head propped on several pillows D
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?A) Capillary refill of fingers on right hand is 3 secondsB) Skin warm to touch and normally coloredC) Client reports prickling sensation in the right hand D) Slight swelling of fingers of right hand C
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolate. Which action is a nursing priority? A) Protect the eyes of the neonate from the heat lampB) Monitor the neonate’s temperatureC) Warm all medications and liquids before giving D) Avoid touching the neonate with cold hands B
The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse’s immediate action?A) Periorbital edemaB) Dizziness spells C) LethargyD) Shortness of breath B
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider orderingA) Pulmonary embolectomyB) Vena caval interruptionC) Increasing the coumadin therapy to an INR of 3-4D) Thrombolytic therapy B
A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis? A) Menopause at age 50B) Has taken high doses of steroids for arthritis for many years C) Maintains an inactive lifestyle for the past 10 yearsD) Drinks 2 glasses of red wine each day for the past 30 years B
Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that itA) Considers client and staff needsB) Conserves time for planningC) Frees the nurse manager to handle other priorities D) Allows for requests about special privileges A
A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process?A) Regulate the neonate’s temperature using a radiant heaterB) Withhold feedings while under the phototherapyC) Provide water feedings at least every 2 hoursD) Protect the eyes of neonate from the phototherapy lights C
“The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?A) “”I usually avoid driving at night since lights sometimes seem to make things blur.””B) “”I take half of the usual dose for my sinuses to maintain my blood pressure.””C) “”I have to sit at the side of the pool with the grandchildren since I can’t swim with this eye problem.””D) “”I take extra fiber and drink lots of water to avoid getting constipated.””” D
On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this byA) placing an obturator at the client’s bedsideB) having another nurse assist with the procedureC) fastening clean tracheostomy ties before removing old tiesD) Withdraw catheter in a circular motion C
Which contraindication should the nurse assess for prior to giving a child immunizations?A) Mild cold symptomsB) Chronic asthmaC) Depressed immune systemD) Allergy to eggs C
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care isA) Sedation as needed to prevent exhaustionB) Antibiotic therapy for 10 to 14 daysC) Humidified air and increased oral fluidsD) Antihistamines to decrease allergic response C
A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 degrees Celsius (95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress may lead to what complication?A) Lowered BMRB) Reduced PaO2C) LethargyD) Metabolic alkalosis B
In addition to standard precautions, a nurse should implement contact precautions for which client?A) 60 year-old with herpes simplexB) 6 year-old with mononucleosisC) 45 year-old with pneumoniaD) 3 year-old with scarlet fever A
Which of the following situations is most likely to produce sepsis in the neonate? A) Maternal diabetesB) Prolonged rupture of membranes C) Cesarean deliveryD) Precipitous vaginal birth B
Which client is at highest risk for developing a pressure ulcer?A) 23 year-old in traction for fractured femurB) 72 year-old with peripheral vascular disease, who is unable to walk without assistance C) 75 year-old with left sided paresthesia and is incontinent of urine and stoolD) 30 year-old who is comatose following a ruptured aneurysm of urine and stool C
“A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?A) Vary the interview style for each candidate to learn different techniquesB) Use simple questions requiring “”yes”” and “”no”” answers to gain definitive information C) Obtain an interview guide from human resources for consistency in interviewing each candidateD) Ask personal information of each applicant to assure meeting of job demands” C
“A client who is 12 hour post-op becomes confused and says: “”Giant sharks are swimming across the ceiling.”” Which assessment is necessary to adequately identify the source of this client’s behavior?A) Cardiac rhythm stripB) Pupillary responseC) Pulse oximetryD) Peripheral glucose stick” C
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?A) Call the health care providerB) Access the site by cutting a window in the castC) Record the findings in the nurse’s notes onlyD) Outline the spot with a pencil and note the time and date on the cast D
A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?A) Disruption of fetal glucose supplyB) Pancreatic insufficiencyC) Maternal insulin dependency D) Reduced glycogen reserves A
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?A) IrritabilityB) Slight edema at siteC) Local tendernessD) Temperature of 102.5 F D
“The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?A) “”Your child must use a care seat until he weighs at least 40 pounds.””B) The child must be 5 years of age to use a regular seat belt.C) “”Your child must reach a height of 50 inches to sit in a seat belt.””D) “”The child can use a regular seat belt when he can sit still.””” A
A 16 year-old boy is admitted for Ewing’s sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includesA) Amputation just above the tumorB) Surgical excision of the massC) Bone marrow graft in the affected leg D) Radiation and chemotherapy D
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do initially?A) Conduct guided imagery or distractionB) Ensure that the stump is elevated for the initial dayC) Wrap the stump snugly in an elastic bandage D) Administer opioid narcotics as ordered B
What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?A) Set good examples themselvesB) Protect their child from outside influencesC) Make sure their child understands all the safety rulesD) Discuss the consequences of not wearing protective devices A
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?A) Venturi maskB) Partial rebreather maskC) Non-rebreather maskD) Simple face mask C
“The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?A) “”I’m going to try feeding my baby some rice cereal.””B) “”When he wakes at night for a bottle, I feed him.””C) “”I dip his pacifier in honey so he’ll take it.””D) “”I keep formula in the refrigerator for 24 hours.””” C
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client’s total protein level is reported as 4.5. Which of the following would the nurse anticipate?A) Additional potassium will be given IVB) Blood for coagulation studies will be drawn C) Total parenteral nutrition (TPN) will be started D) Serum lipase levels will be evaluated C
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?A) The newborn needs additional assessments B) The mother should breast feed more often C) A change to formula is indicatedD) The loss is within normal limits D
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?A) The client’s self-report is the most important considerationB) Cultural sensitivity is fundamental to pain managementC) Clients have the right to have their pain relievedD) Nurses should not prejudge a client’s pain using their own values A
“A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “”I refuse both radiation and chemotherapy because they are ‘hot.'”” The next action for the nurse to take is toA) Document the situation in the notesB) Report the situation to the health care providerC) Talk with the client’s family about the situationD) Ask the client to talk about the concerns about the “”hot””treatments” D
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?A) BenzodiazepinesB) Chlorpromazine (Thorazine)C) Succinylcholine (Anectine)D) Thiopental sodium (Pentothal Sodium) C
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which changes would require the nurse’s immediate attention?A) Increased restlessnessB) TachycardiaC) Tracheal deviationD) Tachypnea
Which approach is a priority for the nurse who works with clients from many different cultures?A) Speak at least 2 other languages of clients in the neighborhoodB) Learn about the cultures of clients who are most often encounteredC) Have a list of persons for referral when interaction with these clients occurD) Recognize personal attitudes about cultural differences and real or expected biases D
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention?A) Decreased blood pressure and respirations.B) Flushing and headache.C) Restlessness and palpitations.D) Increased heart rate and blood pressure. C
The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?A) Encourage child to engage in activities in the playroomB) Promote independence in activities of daily livingC) Talk with the child and allow him to express his opinionsD) Provide frequent reassurance and cuddling A
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care provider ordering?A) Oral Coumadin therapyB) Heparin 5000 units subcutaneously b.i.d.C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control valueD) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value D
The nurse is caring for a client with Hodgkin’s disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience A) High feverB) NauseaC) Face and neck edema D) Night sweats B
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? A) 1 year of ageB) 2 years of ageC) 3 years of ageD) 4 years of age B
“Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first?A) An elderly client who stated that “”My awful pain in my right side suddenly stopped about 3 hours ago.””B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancyC) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past weekD) A teenager with a history of falling off a bicycle and did not hit the handle bars” A
A client with a panic disorder has a new prescription for Xanax (Alprazolam). In teaching the client about the drug’s actions and side effects, which of the following should the nurse emphasize?A) Short-term relief can be expectedB) The medication acts as a stimulant C) Dosage will be increased as tolerated D) Initial side effects often continue A
“Which of these questions is priority when assessing a client with hypertension? A) “”What over-the-counter medications do you take?””B) “”Describe your usual exercise and activity patterns.””C) “”Tell me about your usual diet.””D) “”Describe your family’s cardiovascular history.””” A
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?A) Rotation of injection sitesB) Insulin mixing and preparationC) Daily blood sugar monitoringD) Regular high protein diet C
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?A) An adolescent taking medications for acneB) An elderly client living in a retirement center taking prednisoneC) A young adult at home taking a prescribed amino glycoside D) A hospitalized middle aged client receiving clindamycin D
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?A) Decreased breath sounds in right lower lobeB) Aspiration of a residual of 100cc of formulaC) Decrease in bowel soundsD) Urine output of 250 cc in past 8 hours A
The nurse is preparing to take a toddler’s blood pressure for the first time. Which of the following actions should the nurse do first?A) Explain that the procedure will help him to get wellB) Show a cartoon character with a blood pressure cuffC) Explain that the blood pressure checks the heart pumpD) Permit handling the equipment before putting the cuff in place D
A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A) digoxin (Lanoxin)B) diltiazam (Cardizem)C) nitroglycerine ointmentD) metoprolol (Toprol XL) A
To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy?A) Anti-inflammatory agentB) High doses of B complex vitaminsC) Amino glycoside antibioticD) Two anti-tuberculosis drugs