1. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a
... [Show More] limited support system. Which of the following is the priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding child care options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Inform the client of available community resources
2. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Clear fluid drainage from the nares
3. A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Profuse milky white discharge
4. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
This technique decreases the risk of subcutaneous infiltration
10. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Dry the newborn
11. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
D. Clients who have a history of viral hepatitis are unable to donate blood
Clients who have a history of viral hepatitis are unable to donate blood
12. A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts
Work with the client to create a flexible daily schedule
13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity
Malnutrition
14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid
Check the FHR
15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose meal times
D
16. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery
Asymmetric, with variegated coloring
17. A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead
Dim the lights in the room prior to the examination
18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom
Administers PO analgesia 20 minutes prior to irrigation
19. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
Maintain the head at a midline position
20. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action?
A. Notify the facility operator
B. Close the fire doors on the unit
C. Turn off oxygen sources
D. Put out the fire with the appropriate extinguisher
Close the fire door on the unit
21. A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others
The provider can prescribe restraints if your parent tries to harm others
22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
Hallucinations
23. A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
Bounding pulses
24. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
Hyperemesis
25. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?
A. Heart rate greater than 60/min
B. Pedal pulses 2+
C. Pacer spikes after the QRS complex
D. Distended jugular veins
Heart rate greater than 60/min
26. A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective?
A. Decreased blood pressure
B. Weight loss
C. Decreased inflammation
D. Absence of seizures
Weight loss
27. A nurse at the family planning clinic triages several client over the phone. Which of the following clients should the nurse instruct to come to the clinic?
A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting
B. A client who had an intrauterine device inserted yesterday and has cramping and bleeding
C. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding
D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday
A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday
28. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B.. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketones
HbA1C
29. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?
A. Wear an N95 respirator
B. Insert an indwelling urinary catheter to monitor urinary output
C. Monitor the client's vital signs every 8 hr
D. Use a dedicated stethoscope
Use a dedicated stethoscope
30. A nurse is planning care for a client who has a gambling disorder. Which of the following instructions should the nurse provide to the client?
A. Participate in a 12-step program
B. Plan to take clozapine for the next 6 months
C. Use systematic desensitization to decrease gambling behaviors
D. Learn to use projection to adapt to stressful experiences
Participate in a 12-step program
31. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
B. Tell the client to avoid drinking fluids 1 hr before bedtime
C. Schedule routine care tasks during hours when the client is awake
D. Advise the client to leave the television in the room on when trying to fall asleep
Tell the client to avoid drinking fluids 1 hr before bedtime
32. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
A. Clothe the newborn in light cotton
B. Check the newborn's temperature every 8 hrs.
C. Administer 120 mL of water between feedings
D. Place the newborn 45 cm from the light source
Place the newborn 45 cm from the light source
33. A nurse is providing teaching to a client who is at 8 week gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include?
A. Brush teeth immediately after eating
B. Lay down for 30 min after meals
C. Drink 12 oz of water with each meal
D. Eat a dry carbohydrate before getting out of bed
Eat a dry carbohydrate before getting out of bed
34. A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter line. Which of the following information should the nurse include in the teaching?
A. Your PICC line will allow long-term access for antibody therapy
B. You should use a 5-milliliter barrel syringe to flush your PICC line at home
C. Your PICC line must be placed in your nondominant arm
D. You should immobilize the arm with the PICC line using a sling
Your PICC line will allow long-term access for antibiotic therapy
35. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make?
A. Art therapist
B. Speech-language pathologist
C. Social worker
D. Recreational therapist
Social worker
36. A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic?
A. You looked like you would be the most likely to talk back with me
B. Let's go see what activities are going on outside
C. Why shouldn't I talk to you? You looked lonely
D. You're curious why I am interested in you and not the others?
You're curious why I am interested in you and not the others [Show Less]