Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medicat... [Show More] ion?
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?
2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should:
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:
6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?
7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority?
8 A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:
9 A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve got HIV now." What is the appropriate response by the nurse?
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? Type your answer in the space provided.
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:
13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of:
14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences:
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the nurse to contact the prescribing physician before administering the medication?
16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?
17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT?
18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:
19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply.
20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peaud'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client’s breast?
21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:
22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I’m never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?
23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?
24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note?
25 An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?
26 A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?
27 A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?
28 A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads “4 mg/mL.” How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided.
29 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:
30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting:
31 A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?
32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply.
33 A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:
34 A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply.
35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.
36 A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client’s medical record? Select all that apply.
37 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply.
38 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:
39 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply.
40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:
41 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:
42 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I’m really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should:
43 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?
44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:
45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.
46 A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside?
47 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:
48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:
49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer.
50 A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?
51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:
52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation?
53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client?
54 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client?
55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred?
56 A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?
57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?
58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.
59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided.
60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:
61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions?
62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?
63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client?
64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?
65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?
66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with:
67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:
68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:
69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?
71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:
72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be:
73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?
74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?
75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.
76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock?
77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?
78 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:
79- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?
80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is:
81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?
82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?
83 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse?
84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?
85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:
87- A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client?
88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician?
89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?
90 - A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?
91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply.
92 -A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.
93- A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's:
94- A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I’ll be able to do these feedings by myself." Which response by the nurse is appropriate?
95- A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to:
96- A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next?
97 -A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse
98 -A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it’s probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as:
99 -A nurse notes documentation in the client’s medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note?
100- A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to:
101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication?
102 -A client with post–traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?
103- A nurse provides information to a client with peripheral vascular disease about ways to limit the disease’s progression. Which of the following measures does the nurse tell the client to take? Select all that apply.
104 -A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?
105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:
106 A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic?
107 A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse?
108- A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:
109 -Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?
110 -A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder?
111 -A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms?
112 -A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care?
113 -A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:
114 -A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse?
115 -A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?
116 -A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with:
117 -A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse?
118- A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply.
119- A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that:
120 -A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching?
121- A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:
122 -An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply.
123 - A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client?
124- An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note?
125 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate?
126 A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation?
127 -A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?
128 -A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction?
129 -A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test:
130- A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record?
131 A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside?
132 -Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: [Show Less]