1.An elderly Cantonese-speaking client has been admitted to the emergency

1.An elderly Cantonese-speaking client has been admitted to the emergency department after suffering a fall and suspected hip fracture in her home. Emergency medical services personnel have reported to the nurse that the client speaks no English. Who is the best person to perform translation services?-A hospital translator 2.A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents?The correct procedure for auscultating the client’s abdomen for bowel sounds is to: - 3.. A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first?

4.A client is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity.The client states, "I am the savior of the city." The family states that the client has hardly slept or eaten for days. Which client need is a priority in the nurse's plan of care?

5.A client had an appendectomy 2 days ago and is now presenting with purulent drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What would be the most appropriate action by the nurse?

6.A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

7.Adolescents and adults who were sexually abused as children commonly mutilate

themselves. The nurse interprets this behavior as:

8.A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to

• A nurse is developing a care plan for a client recovering from a serious thermal burn.

What does the nurse determine is the priority goal of therapy?

10.A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury.Which statement by the father would most alert the nurse to the need for a psychiatric consultation?

11.A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?

12.At which time should the nurse instruct the client to take ibuprofen, prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?

13.Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

14.A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing?-27 gtt/min 15.Before administering the evening dose of an ordered medication, a nurse on the evening shift finds an unlabeled, filled syringe in a client's medication drawer. What should the nurse do?

16.A 13-year-old child has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, what should the nurse suggest the mother do first?

17.A newly-admitted client has told the nurse, "I always take a thyroid pill each morning but I do not think I have been prescribed it here in the hospital." The nurse confirms This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00

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that the client's medication orders do not include this. What is the nurse's best action?

18.While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?

19.The health care provider (HCP) prescribes a serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At what time should the nurse plan to have the blood specimen obtained?g times should the nurse plan to have the blood specimen obtained?

20.While making a home visit to a multigravida 2 weeks after the birth of viable twins at 38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client’s apartment is clean, and nothing appears out of place. The client tells the nurse that she completed

three loads of laundry this morning. A priority need for this client is:

21.A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method?

22.A client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which response by the nurse is best?

23.Which statement indicates that a client with esophageal reflux disorder understands the dietary teaching?

24.A client comes to the emergency department reporting pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?

25.The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use?

26.The nurse is planning care for an infant with bronchiolitis. What is the nurse’s priority intervention for this child?

27.Which of the following behaviors would indicate to the nurse that follow-up is needed for a client having difficulty attaching to her newborn?

28.A 20-year-old female client says, “I feel that my vaginal opening constricts whenever I am about to have intercourse. I seem to have no control over it.” Which of the following terms should the nurse use to document the client’s condition?

29.After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

30.The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort?

31.A charge nurse is developing the client care assignments for the shift. Which client is most appropriately assigned to a licensed practical nurse (LPN)?

32.A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00

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33.A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which of the following results are consistent with this disorder?

34.Which of the following actions performed by a nurse will increase the risk of liability?Select all that apply.

35.The nurse is caring for a client in the medical unit. The nurse receives a health care provider’s order for Hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse is most correct to understand that this treatment is common in clients with which disease process?

36.A nurse on a night shift entered an elderly client’s room during a scheduled check and discovered the client on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

37.A nurse is teaching a client with multiple sclerosis (MS). When teaching the client

how to reduce fatigue, the nurse should tell the client to:

38.Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?

39.An adolescent client, diagnosed with depression and a suicide attempt, is admitted to an inpatient adolescent psychiatric unit. The nurse documents that “the client describes a recent breakup of a dating relationship with an emotionless tone and a flat facial expression.” Which nursing diagnosis would be a priority in the client’s plan of care?

40.A client at term arrives in the labor unit experiencing contractions every 4 minutes.After a brief assessment, she's admitted and an electric fetal monitor is applied.Which finding alerts the nurse to an increased risk for fetal distress?

41.A nurse explains to a client with thyroid disease that the thyroid gland normally

produces:

42.Which guidelines define and regulate what the nurse may and may not do as a professional?

43.What advice should a nurse give to the parents of a 2-year-old child who frequently throws temper tantrums?

44.The mother of a 10-year-old girl with diabetes asks the nurse’s advice about whether or not her child, who has always been compliant with treatment, should be allowed to go trick-or-treating on Halloween with several friends. The nurse should tell the

mother:

45.The family of a laboring client is distressed to discover that the on-call physician is a male. The client’s husband forbids the physician from providing care for his wife.What is the nurse’s best strategy in which to provide care in labor and birth when confronted with a cultural conflict?

46.A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

47.A nurse is assisting a client with a chronic respiratory disease to walk in the hallway.The nurse observes as the client’s SpO2 drops from 94% to 88% during ambulation.Which of the following is the appropriate action of the nurse?

48.A client with a history of Addison’s disease is experiencing weakness and headache.The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which of the following would the nurse expect to administer?

49.A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important? This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00

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50.The nurse is teaching a client with type I diabetes self-administration of insulin.Which statement by the client would be an expected outcome of the teaching session? Select all that apply.

51.The nurse is caring for a child with hemophilia who is actively bleeding from the leg.

The nurse should apply:

52.The nurse is caring for a client following a motor vehicle incident with head trauma suspected of diabetes insipidus. Which nursing intervention is appropriate?

53.The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse’s priority intervention?

54.Which is an expected outcome of pursed-lip breathing for clients with emphysema?

55.A client with suspected inhalation anthrax is admitted to the emergency department.Which action by the nurse takes the highest priority?

56.A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks?

57.Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance?

58.A client with bipolar disorder, manic phase, shows little interest in eating. To help the

client meet recommended daily allowances of nutrients, the nurse should:

59.A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl (70mmol/L). The most therapeutic pharmacologic intervention would be to administer 60.A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F (38.1° C).Which outcome would be a priority for this client?

61.A client with emphysema is at a greater risk for developing what acid–base imbalance?

62.Two days after the client donated the right lobe of the liver to his father, he tells the nurse, “I was pressured by my family to donate a piece of my liver.” What is the nurse’s priority intervention in this situation?

63.After administering the prescribed medications, which of the following clients requires immediate intervention?

64.The nurse has taught the wife of a client who experienced traumatic vision loss strategies for effectively interacting with her spouse. Which statement by the wife indicates that the health teaching was successful?

65.How should a nurse prepare a suspension before administration?

66.Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?

67.A client is admitted at 30 weeks' gestation with contractions every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2 g/h. How will the nurse know the medication is having the intended effect?

68.During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?

69.The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan?

70.Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00

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