Nursing Care Guidelines for Various Conditions | Exams Nursing | Docsity (2024)

Download Nursing Care Guidelines for Various Conditions and more Exams Nursing in PDF only on Docsity! Ati Rn Comprehensive Predictor 2019 Form A B C Advanced Questions And Answers A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. - CORRECT ANSWER -A. Administer the feeding over 30 min. 2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D.Constipation for 2 days. - CORRECT ANSWER -B. Apical pulse 58/min A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family want the client to have life-sustaining measures. Which of the following action should the nurse take? A.Arrange for an ethics committee meeting to address the family's concerns. B. Support the family's decision and initiate life-sustaining measures. C. Complete an incident report. D.Encourage the family to contact an attorney. - CORRECT ANSWER -A. Arrange for an ethics committee meeting to address the family's concerns. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. - CORRECT ANSWER -A. Store the glasses in a labeled case. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client's room. B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. D. Wear a mask when changing the linens in the client's room. - CORRECT ANSWER -C. Wear gloves when providing care to the client. A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. - CORRECT ANSWER -D. Obtain a cardiac rehabilitation consultation. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. - CORRECT ANSWER -A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. D. Allow extra time for the client to perform tasks. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. - CORRECT ANSWER -B. CINAHL. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. - CORRECT ANSWER -D. Administer 100% humidified oxygen. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client's mouth when he is ready to eat. B. Provide total care in performing the client's ADLs. C. Maintain the client on bed rest. D. Place the client's left arm on a pillow while he is sitting. - CORRECT ANSWER -D. Place the client's left arm on a pillow while he is sitting. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client's situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. - CORRECT ANSWER -A. Confront the client about this behavior. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client's room. B. Limit the client's visitors to 30 min per day. C. Discard the client's linens in a double bag. D. Discard the radioactive source in a biohazard bag - CORRECT ANSWER -B. Limit the client's visitors to 30 min per day. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea - CORRECT ANSWER -A A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation. C. Post term with oligohydramnios. D. Chorioamnionitis - CORRECT ANSWER -C. Post term with oligohydramnios. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. "What are the indications that my baby needs an IV?" Which of the following responses should the nurse make? A. "Your baby needs an IV because she is not producing any tears" B. "Your baby needs an IV because her fontanels are budging" C. "Your baby needs an IV because she is breathing slower than normal" D. "Your baby needs an IV because her heart rate is decreasing" - CORRECT ANSWER -A. "Your baby needs an IV because she is not producing any tears" A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be over hydrated" - CORRECT ANSWER -C. "Rise slowly when getting out of bed" A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. - CORRECT ANSWER -D. Review the facility policy about the use of an interpreter. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? A. Urine output 20 ml/hr. B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. D. Contractions every 5 min that last 30 seconds. - CORRECT ANSWER -B. Montevideo units constantly 300 mm Hg. A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs. D. Providing crisis intervention through a mobile counseling unit. - CORRECT ANSWER -A. Teaching parenting skills to expectant mothers and their partners. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client's blood type with the type and cross match specimens. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client's identification band matches the number on the blood unit. - CORRECT ANSWER -A. Match the client's blood type with the type and cross match specimens. A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. "I have been experiencing more tremors in my left arm than before" B. "I noticed that I am having a harder time holding on to my toothbrush" C. "Lately, I feel like my feet are freezing up, as they are stuck to the ground" D. "Sometimes, I feel I am making a chewing motion when I'm not eating" - CORRECT ANSWER -C. "Lately, I feel like my feet are freezing up, as they are stuck to the ground" A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. - CORRECT ANSWER -A. Increased creatine. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. "Did the doctor discuss with you that there was a change in this medication?" B. "I recommend that you take this medication as prescribed" C. "Do you know why this medication is being prescribed to you?" D. "I will call the pharmacist now to check on this medication" - CORRECT ANSWER -D. "I will call the pharmacist now to check on this medication" A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. - CORRECT ANSWER -A. Use three pronged grounded plugs. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. - CORRECT ANSWER -D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat". B. A client who has gout and states, "I can continue to eat anchovies on my pizza." C. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium". D. A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with a full glass of water". - CORRECT ANSWER -B. A client who has gout and states, "I can continue to eat anchovies on my pizza." A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? C. Auscultate the newborn's apical pulse for 60 seconds. D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence. - CORRECT ANSWER -C. Auscultate the newborn's apical pulse for 60 seconds. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. - CORRECT ANSWER -B. Apply fetal heart rate monitor. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. - CORRECT ANSWER -A. Chest pain A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. - CORRECT ANSWER -A. Quality improvement. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. - CORRECT ANSWER -D. Notify the nursing manager about the suspected alcohol use. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. - CORRECT ANSWER -A. Apply zinc oxide ointment to the irritated area. A nurse is reviewing the facility's safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. "Staff will apply identification band after first bath" B. "I will not publish public announcement about my baby's birth" C. "I can remove my baby's identification band as long as she is in my room" D. "I can leave my baby in my room while I walk in the hallway" - CORRECT ANSWER -B. "I will not publish public announcement about my baby's birth" A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. "Morphine 3 mg SQ every 4 hr. PRN for pain." B. "Morphine 3 mg Subcutaneous (Unable to read) C. "Morphine 3.0 mg sub q every 4 hr. PRN for pain." D. "Morphine 3 mg SC q 4 hr. PRN for pain." - CORRECT ANSWER -B. "Morphine 3 mg Subcutaneous (Unable to read) A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. - CORRECT ANSWER -C. Monitor vital signs. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. "Dehydration is treated with calcium supplements" B. "Dehydration can increase the risk of preterm labor" C. "Dehydration associated gastroesophageal reflux" D. "Dehydration is caused by a decreased hemoglobin and hematocrit" - CORRECT ANSWER -B. "Dehydration can increase the risk of preterm labor" A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) - CORRECT ANSWER -C. Answer might be lower platelets. A. Applying a sterile gown after applying a sterile mask B. Balancing the bottle on the sterile basin while pouring the liquid C. Placing the supplies on the sterile field and leaving a 1 inch perimeter D. Putting on sterile gloves after preparing the sterile field. - CORRECT ANSWER -B. Balancing the bottle on the sterile basin while pouring the liquid A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personal (AP). Which of the following actions should the nurse take first to manager her time effective? A. Develop an hourly time frame for tasks B. Schedule daily activities C. Determine goals of the day D. Delegate tasks to the AP - CORRECT ANSWER -C. Determine goals of the day A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? A. I will decrease my daily protein intake to 15 grams per day B. I will use ibuprofen as needed to control abdominal pain C. I will take sucralfate with meals three times per day D. I will avoid food and beverages that contain caffeine - CORRECT ANSWER -D. I will avoid food and beverages that contain caffeine A nurse is reviewing legal issues in health care with a group of newly licensed nurse. Which of the following recommendations should the nurse make? A. Place copies of incident reports in clients medical records. B. Overestimate clients acuity to prevent short staffing C. Ensure that each client has a living will on file prior to treatment D. Obtain personal professional liability insurance coverage - CORRECT ANSWER -C. Ensure that each client has a living will on file prior to treatment A nurse is providing preoperative teaching about patient controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. The PCA will deliver a double dose of medication when you push the button twice B. You can adjust the amount of pain you receive by pushing on the keypad C. Continuous PCA infusions is designed to allow fluctuating plasma medication levels D. You should push the button before physical activity to allow maximum pain control - CORRECT ANSWER -D. You should push the button before physical activity to allow maximum pain control A charge nurse is teaching a newly nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following should the charge nurse include? A. The proxy should make health care decisions for the client regardless of the clients ability to do so B. The proxy can make financial decisions if the need arises C. The proxy can make treatments decisions if the client is under anesthesia D. The proxy should manage legal issues for the client - CORRECT ANSWER -C. The proxy can make treatments decisions if the client is under anesthesia A nurse is caring for a client who has a history of depression and i experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the clients perception of the event B. Notify the clients support person C. Help the client identify identify personal strengths D. Teach the client relaxation techniques - CORRECT ANSWER -A. Confirm the clients perception of the event A nurse is caring for a client who has end stage kidney disease. The clients adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary Glaucoma - CORRECT ANSWER -C. Hypertension A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the clients TV privileges if he does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the client in seclusion when he exhibits signs of anxiety - CORRECT ANSWER -C. Encourage the client to take frequent rest periods A nurse is working with a client who has anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. Lets talk about how you can change your response to stress B. We should establish our roles in the initial session C. Let me show you simple relaxation exercise to manage stress D. We should discuss resources to implement in your daily life - CORRECT ANSWER -B. We should establish our roles in the initial session A staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper mechanics when lifting. Which of the following images indicates the appropriate use of ergonomic principles? - CORRECT ANSWER -Legs apart, Bending the knees, straight back A. This test should be performed after your baby is 24 hours old B. A nurse will draw blood from your babies inner elbow C. Your baby will be given 2 ounces of water to drink prior to the test D. This test will be repeated when your bay is 2 month old - CORRECT ANSWER -A. This test should be performed after your baby is 24 hours old A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? A. I can not be a witness for your consent to donate B. Your name can not be removed once you are listed on the organ donors list C. Your desire to be an organ donor must be documented in writing D. You must be at least 21years old to become an organ donor - CORRECT ANSWER -C. Your desire to be an organ donor must be documented in writing A nurse is caring for a client who is at 33 weeks gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions - CORRECT ANSWER -D. Contractions A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take Mg hydroxide for indigestion B. Drink at least 3 L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in K - CORRECT ANSWER -C. Eat 1g/kg of protein per day A charge nurse is teaching new staff members about factors that increase a clients risk to become violent. Which of the following risk factor should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender - CORRECT ANSWER -A. Previous violent behavior A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? A. Folate B. Zinc C. Iron D. Calcium - CORRECT ANSWER -A. Folate A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client? A. Peanut butter sandwich B. Oatmeal with butter C. Chicken noodle soup D. Celery sticks - CORRECT ANSWER -A. Peanut butter sandwich A nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to following medications requires to follow facility procedure in the safety handling of a bio-hazardous material spill? A. Doxorubicin hydrochloride B. Ampicillin Sodium C. Metronidazole D. Phenytoin - CORRECT ANSWER -A. Doxorubicin hydrochloride A nurse in a providers office is reviewing a female clients medical record during a routine visit. The nurse should recommend increased dietary intake of which of the following vitamins? A. Vit D B. Vit K C. Vit B12 D. Vit A - CORRECT ANSWER -C. Vit B12 A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritualistic behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging - CORRECT ANSWER -D. Preoccupied with aging A nurse is caring for a child who has CF and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussions on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure. D. Perform the procedure prior to meals - CORRECT ANSWER -D. Perform the procedure prior to meals A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Monitor FHR via doppler every 30min B. Restrict the clients total fluid intake to 250 ml/hr C. Give the client protamine if signs of magnesium sulfate toxicity occur D. Measure the clients urine output every hour - CORRECT ANSWER -D. Measure the clients urine output every hour A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 sec B. FHR baseline 170/min C. Early decelerations in the FHR D. Temp 37.4 (99.3) - CORRECT ANSWER -B. FHR baseline 170/min A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? A. Decrease the maintenance infusion rate of IV fluid B. Have protamine sulfate available at the bedside C. Reposition the client side to side each hour D. Monitor the client for HTN - CORRECT ANSWER -C. Reposition the client side to side each hour A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse palm to take during the orientation phase of the relationship? A. Determine previous coping skills used by the client B. Establish the responsibilities of the nurse and client C. Facilitate the clients problem solving skills D> Assist the client in expressing alternative behavior - CORRECT ANSWER -B. Establish the responsibilities of the nurse and client A nurse is reviewing the medical record of 4 clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48 hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is taking bumetanide and has potassium level of 3.6 - CORRECT ANSWER -C. A client who is taking warfarin and has an INR of 1.8 A nurse is caring for a client who is 2 hour pos op following a cardiac catheterization. Which of the following is the priority assessment finding? A. Report of burning sensation at the insertion site B. Absence of pedal pulse in the affected extremity C. Urinary output 25 ml/hr D. SpO2 91% - CORRECT ANSWER -B. Absence of pedal pulse in the affected extremity A nurse in a mental facility receives change of shift report for 4 clients. Which of the following clients should the nurse plan to assess first? A. A client placed in restraints due to aggressive behavior B. A client who will be receiving her first ECT treatment today C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety D. A newly admitted client who has a history of 4.5kg weigth loss in the past 2 months - CORRECT ANSWER -A. A client placed in restraints due to aggressive behavior A nurse is providing discharge teaching about a car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. I can turn my baby car seat around when she weighs 15 pounds B. I can place my baby in the front seat with the airbag turned off C. I will place my baby in a forward facing car seat in my back seat D. I will position my baby at a 45 degree angle in the car seat - CORRECT ANSWER -D. I will position my baby at a 45 degree angle in the car seat A nurse in a clinic is assessing a 6 month old infant. Which of the following findings should the nurse report to the provider? A. Pulse 140 min B. Closed anterior fontanel C. RR 26 min D. Abdominal breathig - CORRECT ANSWER -B. Closed anterior fontanel 1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client's peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client's condition every 15 minutes - CORRECT ANSWER -D. Document the client's condition every 15 minutes A nurse is developing an in service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The clients exhibits impulse behavior B. The client might act seductively C. The client is exceptionally clingy to others E. Lack of situational awareness A nurse is caring for a client who has left hom*onymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan the right to see objects on the right side of her body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the wheelchair on the client's left side. - CORRECT ANSWER -B. Place the bedside table on the right side of the bed. A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? SATA A. have suction equipment available B. Feed client thickened liquids C. Place foods on the unaffected side of the mouth D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed. - CORRECT ANSWER -A. have suction equipment available B. Feed client thickened liquids C. Place foods on the unaffected side of the mouth E. Teach the client to swallow with her neck flexed. A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client's plan of care? SATA A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time - CORRECT ANSWER -A. Speak to the client at a slower rate B. Assist the client to use flash card with pictures E. Give instructions one step at a time A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception - CORRECT ANSWER -C. Inability to recognize familiar objects A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABG's. D. Administer benzocaine spray. - CORRECT ANSWER -A. Position the client in an upright position, leaning over the bedside table. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis - CORRECT ANSWER -B. Respiratory alkalosis A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms - CORRECT ANSWER -D. Bronchospasms A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? SATA A. Oxygen equipment B. Incentive spirometer C. Sterile dressing D. Suture removal kit E. Pulse oximeter - CORRECT ANSWER -A. Oxygen equipment C. Sterile dressing E. Pulse oximeter A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? SATA A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site - CORRECT ANSWER -A. Dyspnea C. Fever D. Hypotension A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevation blood pressure. - CORRECT ANSWER -B. Pale skin E. Elevation blood pressure. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings ever 8 hours. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hours. - CORRECT ANSWER -D. Assess breath sounds every 1 to 2 hours. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Non rebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask - CORRECT ANSWER -B. Venturi mask A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client's respiratory muscles should the nurse include in the plan of care? SATA A. Assist-control B. SIMV C. CPAP D. PSV E. Independent lung ventilation - CORRECT ANSWER -B. SIMV C. CPAP D. PSV A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? SATA A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has Myasthenia Gravis - CORRECT ANSWER -A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has Myasthenia Gravis A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse's priority? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccine. - CORRECT ANSWER -A. Obtain baseline vital signs and oxygen saturation. A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C. Perform a sputum culture. D. Administer an antipyretic medication to promote client comfort. - CORRECT ANSWER -B. Administer oxygen therapy. C. Perform a sputum culture. A. Administer antibiotics. D. Administer an antipyretic medication to promote client comfort. A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas - CORRECT ANSWER -D. Palpation of the orbital areas A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. I should wash my hands after blowing my nose to prevent spreading the virus B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." C. Fluid retention D. Nausea E. Black, tarry stools - CORRECT ANSWER -A. Hypokalemia C. Fluid retention E. Black, tarry stools A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out at much as you used to." D. "Home health services will come to see you so you will not need to get out." - CORRECT ANSWER -A. "There are portable oxygen delivery systems that you can take with you." A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling." - CORRECT ANSWER -D. "I will take in a deep breath and hold it before exhaling." A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? A. Take quick breaths upon inhalation. B. Place you hand over your stomach. C. Take a deep breath in through your nose. D. Puff your cheeks upon exhalation. - CORRECT ANSWER -C. Take a deep breath in through your nose. A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? SATA A. "I can substitute one medication for another if I run out because that all fight infection." B. I will wash my hands each time I cough C. I will wear a mask when I am in a public area D."I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications." - CORRECT ANSWER -B. I will wash my hands each time I cough C. I will wear a mask when I am in a public area .A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need to continue to take the multi-medication regimen for 4 months." B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times." - CORRECT ANSWER -B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A. "Your urine can turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily." - CORRECT ANSWER -C. "Watch for any changes in vision." A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. "You might notice yellowing of your skin." B. "You might experience pain in your joints." C. "You might notice tingling of your hands." D. "You might experience loss of appetite." - CORRECT ANSWER -C. "You might notice tingling of your hands." A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum - CORRECT ANSWER -A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? SATA A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. Prepare for chest tube insertion. - CORRECT ANSWER -B. Obtain a large-bore IV needle for decompression. A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? A. "Notify the provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough." - CORRECT ANSWER -D. "Notify your provider if you experience a productive cough." A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement - CORRECT ANSWER -B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest ex-ray. B. Prepare for chest tube insertion. C. Administer oxygen via high-flow mask. D. Initiate IV access. - CORRECT ANSWER -C. Administer oxygen via high-flow mask. A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety." - CORRECT ANSWER -B. "This medication is given to facilitate ventilation." A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? SATA A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a Hg 15.1 D. A client who has dysphagia E. A client who experienced a drug overdose - CORRECT ANSWER -A. A client who experienced a near- drowning incident B. A client following coronary artery bypass graft surgery D. A client who has dysphagia E. A client who experienced a drug overdose A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? SATA A. Administer antibiotics. B. Provide O2 C. Administer bronchodilators. D. Administer antiviral meds E. Maintain ventilatory support. - CORRECT ANSWER -B. Provide O2 C. Administer bronchodilators. E. Maintain ventilatory support. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? SATA A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E> Dexamethasone - CORRECT ANSWER -A. Fentanyl C. Midazolam A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C. "The transducer should be level with the second intercostal spaced after the line is placed." D. "A chest x-ray is needed to verify placement after the procedure." - CORRECT ANSWER -D. "A chest x- ray is needed to verify placement after the procedure." A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? A. "Can you tell me who visited you today?" B. What high school did you graduate from C. Can you list your current medications?" D. "What did you have for breakfast yesterday?" - CORRECT ANSWER -B. What high school did you graduate from A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching A. HbA1c level greater than 8%- 6.5 - 8 is the target reference. B. Blood glucose level greater than 200 mg/dL at bedtime C. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC D. HbA1c level less than 7% - CORRECT ANSWER -D. HbA1c level less than 7% A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin . Which of the following should the nurse conclude if the client develops ataxia and incoordination? A. The client is experiencing an adverse reaction to rifampin B. Te client is showing evidence of phenytoin toxicity C. The client's seizure disorder is no longer under control - CORRECT ANSWER -B. Te client is showing evidence of phenytoin toxicity A nurse is caring for a client who is 1 hr post op following rhinoplasty. which of the following requires immediate action? A. Increase frequency of swallowing B. Moderate sanguineous drainage on the drip pad C. Bruising to the face D. Absent gag reflex - CORRECT ANSWER -A. Increase frequency of swallowing A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? A. Give scheduled doses of acetaminophen every 6 hr B. Monitor the child cardiac status C. Administer antibiotics via intermittent IV bolus for 24 hr D. Provide stimulation with children of the same age in the playroom - CORRECT ANSWER -B. Monitor the child cardiac status A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? A. Use of tobacco might lead to alcohol and drug abuse B. Smoking in adolescence increases the risk of developing lung cancer later in life C. Use of tobacco decreases the level of athletic ability - CORRECT ANSWER -C. Use of tobacco decreases the level of athletic ability A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? A. Total bilirubin B. Urine ketones C. Serum potassium - CORRECT ANSWER -C. Serum potassium (diuretics that restrain K= hyperkalemia risk) A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? A. "I will let the client know that I am available as the interpreter." B. "I will receive a small fee for interpreting for this client." C. "I am glad I'm available today, but when I'm not, you can use a family member." - CORRECT ANSWER - A. "I will let the client know that I am available as the interpreter." A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? A. A two day old newborn who has a respiratory rate of 70 B. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool C. A 2 day old newborn who has a small amount of blood tinged vagin*l discharge D. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal - CORRECT ANSWER -A. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? A. A client who has a elevated AST level following administration of azithromycin B. A client who is 1 hr postoperative and has hypoactive bowel sounds C. A client who has fractured left tibia and pallor in the affected extremity D. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses - CORRECT ANSWER -C. A client who has fractured left tibia and pallor in the affected extremity A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? A. Weight gain B. Dry mouth→ anticholinergic effects C. sedation s/s neuroleptic malignant syndrome??>> life threatening Sedation D. Shuffling gait→A/E EPS: is an indication of parkinsonism and should be reported - CORRECT ANSWER - D. Shuffling gait→A/E EPS: is an indication of parkinsonism and should be reported A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? A. A client post op following a bowel resection with an NGT set to suction B. A client who has fractured a femur yesterday and is expecting SOB C. A client who sustained a concussion and has unequal pupils D. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs - CORRECT ANSWER -A. A client post op following a bowel resection with an NGT set to suction A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . What should the nurse do? A. Continue to monitor HR B. Stop infusion C. Perform vagin*l examination - CORRECT ANSWER -A. Continue to monitor HR A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? A. Complete an incident report and place it in the client's medical record B. Compare the current infusion with the prescription in the client's medication record. C. Submit a written warning for the nurse involved in the incident. - CORRECT ANSWER -B. Compare the current infusion with the prescription in the client's medication record. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? A. WBC count 2,900 /mm3 B. FAsting blood glucose 100 mg/dl C. Hgb 14 g/Dl D. Heart rate 58/min - CORRECT ANSWER -A. WBC count 2,900 /mm3 A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? A. You may breastfeed unless your nipples are cracked or bleeding. B. You must use a breast pump to provide breast milk. C. You must use nipple shield when breastfeeding. - CORRECT ANSWER -A. You may breastfeed unless your nipples are cracked or bleeding. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? A. Level of consciousness B. Skin turgor C. Bowel Sounds - CORRECT ANSWER -A. Level of consciousness A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? A. Submerge the adolescent feet in ice water B. Cover the adolescent with a the C. Initiate seizure precautions - CORRECT ANSWER -C. Initiate seizure precautions A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? A. Providing pain management B. Offering emotional support C. Initiating IV fluid resuscitation - CORRECT ANSWER -C. Initiating IV fluid resuscitation A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A.Hospice will take good care of your mom, so I wouldn't worry about that. B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. You sound like you have questions about your mom dying. Let's talk about it. - CORRECT ANSWER -B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. You sound like you have questions about your mom dying. Let's talk about it. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? A. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) B. A client who is scheduled for colonoscopy and taking sodium phosphate C. A client who received a Mantoux test 48 hours ago and has induration - CORRECT ANSWER -C. A client who received a Mantoux test 48 hours ago and has induration A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? A. Clarify the source of the referral B. Implement the nursing process C. Schedule a time for the home visit D. Contact the family by phone - CORRECT ANSWER -A. Clarify the source of the referral A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response? A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? A. Documenting the report of pain for a client who is postoperative B. Administering oral fluids to a client who has dysphagia C. Applying a condom catheter for a client who has spinal cord injury - CORRECT ANSWER -C. Applying a condom catheter for a client who has spinal cord injury A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? A. Offer the client saltine crackers between meals Suggest rinsing his mouth with an alcohol-based mouthwash Provide humidification of the room air Instruct the client on the use of esophageal speech - CORRECT ANSWER -A. Offer the client saltine crackers between meals A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? A. Assess effectiveness of antiemetic medication- B. Perform chest compressions during cardiac resuscitation C. Perform a dressing change for a new amputee- D. Apply a transdermal nicotine patch- - CORRECT ANSWER -B. Perform chest compressions during cardiac resuscitation A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? A. The client takes vitamin C daily B. The client has a history of alcohol use disorder C. The client has a history of asthma D. The client takes furosemide twice daily - CORRECT ANSWER -C. The client has a history of asthma A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? A. Increased salivation B. Urinary retention C. Weight loss - CORRECT ANSWER -B. Urinary retention A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? A. Asthma B. Hypertension C. Fibromyalgia D. Fibrocystic breast condition - CORRECT ANSWER -B. Hypertension A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) A. Explain the procedure B. Expected outcome of the procedure C. Potential complications D. Possible alternative treatments E. Cost of the procedure - CORRECT ANSWER -A. Explain the procedure B. Expected outcome of the procedure C. Potential complications D. Possible alternative treatments A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? A. You should not have this procedure if you are allergic to iodine." B. You should not have this procedure if you have a tattoo." C. "The nurse will ask you to wear protective eyewear during this procedure." D. "The nurse will ask you to remove any transdermal patches prior to the procedure." - CORRECT ANSWER -A. You should not have this procedure if you are allergic to iodine." A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? A. Initiate IV fluid replacement B. Start a 24 hour urine collection C. Give aspirin D. encourage ambulation - CORRECT ANSWER -A. Initiate IV fluid replacement A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? A. Summon a security guard B. Explain the risks of leaving C. Complete an incident report - CORRECT ANSWER -B. Explain the risks of leaving A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? A. "I try to respond to the baby quickly ." B. I think the baby should be sleeping through the night by now D. this test should be performed after you baby is 24 hours old - CORRECT ANSWER -D. this test should be performed after you baby is 24 hours old A nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? A. placing a yellow bracelet on a client who is at risk for falls B. administering potassium via IV bolus C. documenting communication with a provider in the progress notes of the client's medical record D. leaving a nasogastric tube clamped after administering oral medication - CORRECT ANSWER -B. administering potassium via IV bolus A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client's maxillary sinus for tenderness. - CORRECT ANSWER -Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. (cheeks area) A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? A. Take pancrelipase B. Complete oral hygiene C. Eat a meal D. Use an albuterol inhaler - CORRECT ANSWER -D. Use an albuterol inhaler A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? A. Offer high-calorie, high protein snacks to the client B. Recommend the family provide the client privacy during meals C. Weigh the client once each day D. Encourage the client to eat foods selected by the dietitian - CORRECT ANSWER -A. Offer high-calorie, high protein snacks to the client A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? A. Non maleficence B. Veracity C. Autonomy D. Justice - CORRECT ANSWER -C. Autonomy A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. - CORRECT ANSWER -A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. hypoglycemia - CORRECT ANSWER -A. Hyponatremia A nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? - CORRECT ANSWER -140 lbs or 63.6 kg (64 kg) A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. I will change my baby's diaper at least every 4 hours B. I will apply an ice pack to my baby's penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healedd. D. I will apply topical lidocaine following each diaper change Teach the parents to keep the area clean. - CORRECT ANSWER -A. I will change my baby's diaper at least every 4 hours A home health nurse is caring for an adult client who reports, "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take? A. encourage the client to increase fluid intake B. initiate a consultation with a speech C. instruct the client that this is due to increased salivary flow that occurs with aging D. recommend an antitussive 30 minutes prior to each meal - CORRECT ANSWER -B. initiate a consultation with a speech A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% - CORRECT ANSWER -C. HbA1c 6.5% C. Triamcinolone acetonide 100 mcg/inhalation D. Zolpidem 10 mg PO one tablet at bedtime - CORRECT ANSWER -A. Lorazepam .5 mg PO one tablet daily A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 D. Xerostomia - CORRECT ANSWER -B. Dysphagia A nurse is assessing a client who is 2 hrs postpartum for uterine atony . Which of the following action should the nurse take? A. Monitor the client's urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client's fundus - CORRECT ANSWER -D. Palpate the client's fundus A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use B. Tape stockinet over monitoring device and cords C. Schedule the client as the last surgery of the day D. Remove poopsocks from the IV - CORRECT ANSWER -B. Tape stockinet over monitoring device and cords A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication. A Dumping syndrome B Ketoacidosis C Hepatotoxicity D Thyroid storm - CORRECT ANSWER -A Dumping syndrome A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft from the client E. Close the door to the client's room - CORRECT ANSWER -B. Wear a lead apron when providing care C. Limit visitors to 30 mins A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem - CORRECT ANSWER -B. Client might feel guilt over some aspect of their loss A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one B. Move your son to a toddler bed when the baby arrives C. Tell your son to kiss the baby D. Teach your son to change the baby diapers - CORRECT ANSWER -A. Offer your son a gift when the baby receives one A nurse is assessing a newborn who has patent ductus arteriosus . Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen D. Bounding pulse - CORRECT ANSWER -D. Bounding pulse A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client's urine output every hour. b. Restrict the client's total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occur. - CORRECT ANSWER -a. Measure the client's urine output every hour. - monitor for toxicity. A nurse is caring for a client who has end stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? a. Hypertension b. Primary glaucoma c. Osteoarthritis d. Amputation - CORRECT ANSWER -a. Hypertension A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight using both Crutches when shifting weight) C. Stepping with his affected leg first when going up stairs (Unaffected First) D. Moving both crutches with the stronger leg forward - CORRECT ANSWER -A. Positioning both hands on the grips with his elbows slightly flexed A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot B. Kick a ball forward C. Climb Stairs with alternate feet D. Ride a tricycle - CORRECT ANSWER -B. Kick a ball forward A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. Im sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner. - CORRECT ANSWER -D. We can review some information to help you select a safe alternative practitioner. A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures - CORRECT ANSWER -C. The client coughs after swallowing A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with preprocedure weight. B. Check the client's serum albumin levels C. Examine for leakage at thes site of the procedure D. Confirm that the client is able to urinate - CORRECT ANSWER -A. Compare the client's current weight with preprocedure weight. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with this leg extended. B. Maintain eye contact with the newborn during feedings. C. Minimize noise in the newborn environment D. Administer naloxone to the newborn - CORRECT ANSWER -C. Minimize noise in the newborn environment ● Reduce environmental stimuli (decrease lights, lower noise level). A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? A. Participate in community drills and mock events. B. Vaccinate susceptible children and adults against smallpox C. Assess types, levels and scopes of disasters. D. Make quarantine preparations for those exposed to anthrax Rationale: Assess First - CORRECT ANSWER -A. Participate in community drills and mock events. A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. (Stage IV Kidney Disease) B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease. - CORRECT ANSWER -A. Severe renal impairment. (Stage IV Kidney Disease) A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area - CORRECT ANSWER -b. Murmur at the mitral area A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? a. Report of occipital headache b. Scratchy, high pitched sound upon chest auscultation c. ECG demonstrates a depressed ST segment d. White, diffuse peritonsillar pustules - CORRECT ANSWER -b. Scratchy, high pitched sound upon chest auscultation .A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? a. Inform the transferring agency of the client's condition. b. Privately interview the client about her condition. c. Notify risk management d. Contact the family regarding the client's condition. - CORRECT ANSWER -b. Privately interview the client about her condition. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will decrease my protein intake during the third trimester"( increase protein for basic growth) b. "I will need to increase my insulin doses later in my pregnancy" c. "I will increase my carbs at breakfast and limit them the rest of the day" d. "I will decrease my calorie consumption during the first trimester"(increase calorie) - CORRECT ANSWER -b. "I will need to increase my insulin doses later in my pregnancy" A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau's sign b. Assess the client's skin turgor c. Check the client's motor strength d. Measure the client's pupil size - CORRECT ANSWER -a. Test the client for Trousseau's sign A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. "I should clean my stoma with warm water"( can use low ph soap and water) b. " My stoma should be bright pink or red"(pink,red and moist) c. "I should change the stoma pouch every day" d. "I should cut my pouch opening ⅛ inch larger than my stoma"(allow expansion) - CORRECT ANSWER - c. "I should change the stoma pouch every day Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full. A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic reaction) d. Polyuria (oliguria, less than 30 ml/hr) - CORRECT ANSWER -a. Hyporeflexia .A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero - CORRECT ANSWER -Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 .A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr - CORRECT ANSWER -a. Administer enalapril 2.5 mg PO twice daily A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen - CORRECT ANSWER -b. Clamp the catheter distal to the injection port A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Establish a toileting schedule for the client. D. Use clothing with buttons and zippers. - CORRECT ANSWER -C. Establish a toileting schedule for the client. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations a. Orthostatic hypotension - b. Dependant Edema- fluid volume excess c. Decreased Hematocrit - fluid volume excess d/t super diltion d. Neck vein distention - fluid volume excess - CORRECT ANSWER -a. Orthostatic hypotension A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Identify Solutions prior to negotiation b. personalize the conflict c. Attempt to understand both sides of the issue d. Focus on how the conflict occurred - CORRECT ANSWER -c. Attempt to understand both sides of the issue Assess the situation first prior to trying to solve it A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Please a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured - CORRECT ANSWER -c. Please a warm moist compress on the site Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding - not without crushing them first b. Dissolve the medications together- some medications can mix others can't c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water- 10ml - CORRECT ANSWER -c. Use a syringe to allow the medications to Flow by gravity The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor c. Seductive Behavior d. Lack of remorse - CORRECT ANSWER -c. Seductive Behavior A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught earlier to control other pain, not pain of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess with the readings of the pt and baby c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. d. I can use my ultrasound picture as a focal point during contractions - CORRECT ANSWER -d. I can use my ultrasound picture as a focal point during contractions A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute b. ST segment elevations_ Remember this could possibly lead to infarctions c. 2 PVCs per minute d. Widened P wave - CORRECT ANSWER -b. ST segment elevations_ Remember this could possibly lead to infarctions A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene ? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Increases the tpn infusion rate each hour until the prescribed rate is achieved - CORRECT ANSWER -c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Initiate NPO status 4 hr prior to the procedure. - CORRECT ANSWER -a. Instruct the client to empty her bladder prior to the procedure. A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver function test d. Serum creatinine - CORRECT ANSWER -c. Liver function test A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure - CORRECT ANSWER -d. Don sterile gloves prior to the procedure . A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Potassium 3.2 mEq/L 3.5 - 5.0 is normal b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL - CORRECT ANSWER -a. Potassium 3.2 mEq/L 3.5 - 5.0 is normal A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? a. "How long have you been hearing the voices?" b. "What are the voices telling you?" c. "Have you taken your medication today?" d. "I realize the voices are real to you, but I don't hear anything." - CORRECT ANSWER -b. "What are the voices telling you?"