NR 452 Capstone FCP Questions and Answers 2023- Chamberlain College of Nursing
1. A nurse on a mental health unit is admitting a client who has
... [Show More] posttraumatic stress disorder.
Which of the following findings should the nurse expect?
1. Talkscontinuouslyabouttheevent
2. Preoccupied with having a serious illness
3. Has difficulty concentrating on a task
4. Experiencesfrequentgrandiosethoughts
2. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take home. Which of the following responses
should the nurse make?
1. "Didthedoctordiscusswithyouthattherewasachangeinthismedication?"
2. "Do you know why this medication is being prescribed for you?"
3. "I will call the pharmacist now to check on this medication "
4. "Irecommendthatyoutakethismedicationasprescribed"
3. A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse
should Identify that which the following findings indicates altered tissue perfusion of the
affected extremity?
1. Purulentdrainageatthesite
2. Faintpedalpulseofleftleg
3. Pain with movement of the left great toe
4. Warmskintemperaturedistaltopinsite
4. 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?
1. "Iwilldecreasemydailyproteinintaketo15gramsperday"
2. "I will use ibuprofen as needed to control abdominal pain"
3. "I will take sucralfate with meals three times per"
4. "Iwillavoidfoodandbeveragesthatcontaincaffeine"
5. A nurse is caring for a client who is in the
(ALS). Which of the following referrals is the nurse's priority?
1. Occupationaltherapist
2. Social worker
3. Speech-language pathologist
4. Psychologist
6. A nurse administers digoxin 0.125 mg PO to an adult client. For which of the following
findings should the nurse notify the provider?
A. Constipationfor2days
B. Potassium level 4.2 mEq/L
advanced stage of amyotrophic lateral sclerosis
C. Digoxin level 1 ng/mL ** normal levels 0.5- 2.0
D. Apicalpulse58/min
7. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which
of the following interventions should the nurse include in the plan?
1. Discontinueultravioletlighttherapyiflesionsbecomeitchy
2. Cover lesions with an occlusive dressing after applying a corticosteroid.
3. Scrub external lesions with a pumice stone
4. Instructtheclienttoaddrubbingalcoholtobathwater
8. A nurse is verifying a record of informed consent for a client who scheduled for surgery.
Which of the following actions should the nurse take?
1. ProvideInformationontheinformedconsentformaboutthebenefitsofthesurgery
2. Confirm the client's signature is authentic
3. Inform the client about the condition that requires treatment
4. Explaintheproceduretotheclientbeforeverifyinginformedconsent.???
9. A nurse is caring for a client who requests the creation of a living will. Which of the
following actions should the nurse take?
1. Scheduleameetingbetweenthehospitalethicscommitteeandclient
2. Determine the client's preferences about postmortem care
3. Evaluate the client's understanding of life sustaining measures
4. Requestaconferencewiththeclient'sfamily
10. A nurse in an emergency department caring for a toddler who has burns following a house
fire. Which of the following actions should the nurse take first?
1. Administerantibioticsprophylacticallytopreventsepsis.
2. Determine the location and depth of the burns.
3. Calculate fluid replacement based on vital signs and urinary output.
4. Checkthemouthforsootandsmokybreath. ABC’S
11. A nurse is caring for an older adult client who has prescriptions for multiple medications.
Which of the following factors should the nurse identify as an age-related change that
increases the risk for adverse effects from medications?
1. Prolongedmedicationhalf-life
2. Increased medication elimination
3. Decreased medication sensitivity
4. Rapidgastricemptying
12. 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?
1. Expresssympathyfortheclient'ssituation.
2. Confront the client about this behavior.
3. Speak assertively to the client.
4. Standwithin30cm(1fuoftheclientwhenspeakingwiththem.
13. A 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 contraindication
to the use of combination oral contraceptives?
A. Hypocalcemia
B. Diverticulosis
C. Hyperthyroidism D. Thrombophlebitis
14. A nurse is creating a plan of care for a female client who has recurrent urinary tract
infections. Which of the following interventions should the nurse include in the plan?
1. Wearloose-fittingunderwear.
2. Take a bubble bath after intercourse
3. Drink four 240 mL (8 oz) glasses of water each day
4. Voideveryto6hrduringtheday. NO
15. A nurse is consulting a pharmacological reference about medication compatibility prior to
administering warfarin to a client. Which of the following medications should the nurse
identify as being incompatible with warfarin?
A. Magnesiumhydroxide
B. Naproxen NSAID’S C. Lisinopril
D. Propranolol
16. A nurse in an emergency department is caring for a client following a motor-vehicle crash.
The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse
expect?
1. Thewithdrawsfrompain.
2. Theclientisorientedtimesthree.
3. The dent is unable to obey commands non.
4. Theclientopenseyestosound.
17. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding. The nurse speaks a different language than the client. The client's partner and 10-
year-old child are accompanying her. Which of the following actions should the nurse take to
gather the client’s admission data?
1. Requestafemaleinterpreterthroughthefacility
2. Ask nursing student who speaks the same language as the client to translate
3. Allow the client’s partner to translate
4. Havetheclient’schildtranslate
18. A nurse is planning care for a client who is recovering from an acute myocardial infarction
that occurred 3 days ago. Which of the following interventions should the nurse Include?
1. PerformanECGevery12hr.
2. Place the client in a supine position while resting.
3. Draw a troponin level every 4hr.
4. Obtainacardiacrehabilitationconsultation.
19. A nurse in the infectious disease division of the local health department is caring for a
client. Which of the following infections should the nurse identify should be reported to the
health department?
1. Clostridiumdifficile
2. Human papilloma virus
3. Herpes simplex virus
4. Chlamydiatrachomatis
20. A nurse is administering an intradermal injection for allergy testing to a client. Into which
of the following sites should the nurse inject the medication? (You will find hot spots to select
in the artwork below. Select only the hot spot that corresponds to your answer
21. A nurse is caring for a client who has compartment syndrome following the application of
a cast to the leg. Which of the following actions should the nurse take?
1. Applyicetotheextremity
2. Checktheclient’spedalpulses.
3. Administer a dose of antiemetic medication
4. Positiontheclient’slegabovetheleveloftheheart
22. A nurse is caring for a client who speaks a language different from the nurse. Which of the
following actions should the nurse take?
1. Reviewthefacilitypolicyabouttheuseofaninterpreter.
2. Request a family member or friend to interpret information for the client.
3. Direct attention toward the interpreter when speaking to the client.
4. Requestaninterpreterofadifferentsexfromtheclient.
23. A nurse is providing discharge instructions about newborn safety to a client who is 2 days
postpartum. Which of the following instructions should the nurse include?
1. Changesmokedetectorbatterieseveryotheryear.
2. Useacarseatwhentravelingbyairplane.
3. Place a plastic waterproof sheet over the crib bedding.
4. Laythebabyonhisstomachtonapduringthedaytime.
24. A nurse manager is reviewing the steps of the progressive discipline process prior to
counseling a staff member who exhibits unprofessional behavior. Identify the sequence of
steps the nurse manager should plan to take in response to the staff members conduct (Move
the steps into the box on the right placing them order of performance. Use all the steps)
Set up a meeting to speak the staff member about the behavior Verbally remind the staff
member of the expected chances Give the staff member a written warning about the
behavior Suspend the staff member from work for several days
Dismiss the staff member from employment at the
25. A nurse is assessing a client who has a prescription for hydrocodone PRN. Which of the
following adverse effects should the nurse identity as priority for withholding this medication
and notifying the provider?
1. Hypotension
2. Nausea
3. Constipation ** normal side effect
4. Urinaryretention
26. A nurse is initiating bladder retraining for a client who has urge urinary incontinence.
Which the following instructions should the nurse give the client?
1. "Takeyourdiureticmedicationwithyoureveningmeal"
2. "Decrease your intake of cranberry juice"
3. "Plan to urinate every 3 hours while you are awake"
4. "Limityourfluidintaketo500perday"
27. A nurse is teaching participants at a community center about advance directives. Which of
the following information should the nurse include in the teaching?
1. Aclientmustcreateadonotresuscitateorderwhencompletingadvancedirectives.
2. A health care surrogate makes health care decision when the client is no longer able.
3. Advance directives cannot be changed once implemented.
4. Assigningahealthcaresurrogaterequireslegalconsultation.
28. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors
should the nurse identify indicating the client is experiencing mania?
1. Theclientspeaksusingwordsalad.
2. The client speaks using echopraxia.
3. The client is socially withdrawn.
4. The client is easily distracted by external stimuli.
29. A nurse is caring for a client who has colon cancer and is terminally ill. The client states, "I
can't believe I'm going to die." Which of the following statements should the nurse make?
1. "Itmightbecomfortingtoprayforspiritualassistance."
2. "Your doctor will make sure you won't be in much pain "
3. "Tell me what is important to you right now."
4. "Ifeltthesamewayyou'refeelingwhenmymotherdied"
30. A home health nurse is teaching a new parent about caring for his 1-week-old infant.
Which of the following statements by the client indicates an understanding of the teaching?
1. "Iwillavoidpickingupmybabytoooftentokeepfromspoilinghimwill"
2. "Iwillplaceatickingclocknearbytosoothemybabythroughouttheday"
3. "I will hang a pastel-colored mobile 24 inches above my baby's crib. "
4. "Icanuseafirmpillowtopropupthebottlewhenfeedingmybaby."
31. A nurse is assessing a client who is receiving daily
identify that which of the following findings might indicate an medication?
1. Weightgain
2. Blurred vision
3. Difficulty swallowing
4. Highbloodpressure
. The nurse should to this
aspirin therapy
allergic reaction
32. A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse include?
1. Discouragetheclientfromexploringirrationalfears.
2. Provide negative reinforcement for ritualistic behaviors.
3. Allow the client enough time to perform rituals.
4. Givetheclientautonomyinschedulingactivities.
33. A nurse is planning care for a school-age child who is 4 hr postoperative following
appendicitis. Which of the following actions should the nurse include in the plan of care?
1. Givecromolynnebulizedsolutionevery8hr.
2. Offer small amounts of clear liquids 6 hr following surgery.
3. Apply a warm compress to the operative site once daily.
4. Administeranalgesicsonascheduledbasisforthefirst24hr.
34. A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to
deal with stress. Which of the following actions should the nurse take to assist the client in
maintaining self-control of the behavior?
1. Givepositivefeedbacktotheclientforusingadaptivestrategies.
2. Discuss strategies with the client to reduce alcohol consumption gradually.
3. Provide the client with periods of alone time for reflection in their behavior.
4. Havetheclient’spartnerassumeresponsibilityformonitoringtheclient’salcoholintake.
35. A nurse is providing dietary teaching to a client who has hyperlipidemia. The nurse should
include in the teaching that which of the following oils contains the lowest amount of
saturated fats?
1. Canolaoil
2. Olive oil
3. Palm oil
4. Coconut
36. A nurse is teaching a childbirth education class and is discussing sexual intercourse during
pregnancy. Which of the following statements should the nurse make?
1. "Frequentintercourseincreasestheriskformiscarriageinearlypregnancy"
2. "You should limit the frequency of intercourse after 34 weeks of pregnancy"
3. "Your sexual desire might increase during the first trimester of pregnancy"
4. "Thefemalesuperiorpositioncanbeusedduringthethirdtrimesterofpregnancy"
37. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of
the following prescriptions should the nurse expect the provider to prescribe?
1. Atorvastatin
2. Enoxaparin
3. Interferon beta-1a
4. Amoxicillin
38. A nurse caring for a client who is labor and receiving oxytocin. Which of the following
findings indicates that the nurse should increase the rate of infusion?
1. Urineoutputof20mL/hr??
2. Montevideo units consistently 300 mmHg
3. Contractions every 5 min that last 30 seconds
4. FHRpatternwithabsentvariability
39. A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which
of the following information should the nurse include in the teaching?
1. "Whileeating,youshoulddrinkliquidsfrequently."
2. "Duringmeals,youshouldeatfoodswithahigh-caloriecontentfirst."
3. "You should eat hot foods to reduce your sense of fullness during a meal"
4. "Lunchshouldbeyourlargestmealoftheday"
40. A nurse is providing teaching about the administration of gastrostomy tube feeding to the
parents of a school age child. Which of the following Instructions should the nurse include?
1. Administerthefeedingover30min
2. Place the child in a supine position after the feeding
3. Warm the formula in the microwave prior to administration
4. Changethefeedingbagandtubingevery3days
41. A nurse in a community clinic is caring for a client who requests assistance with smoking
cessation. The nurse should expect a prescription for which of the following medications?
A. Chlordiazepoxide B. Clonidine
C. Bupropion
D. Naltrexone
42. A newly licensed nurse is unsure if an assigned task is within their scope of practice.
Which of the following resources should the nurse consult?
1. Writtenprescriptiontheprovider
2. Verbal direction from the nurse manager
3. State Nurse Practice
4. Institutionalpoliciesandprocedures
43. A nurse is providing discharge teaching about car seat safety to a parent of a newborn.
Which of following statements by the parent indicates an understanding of the teaching?
1. "Iwillpositionmybabyata45-degreeangleinthecarseat."
2. "I will place my baby in a forward-facing car seat in my back seat"
3. "I can place my baby in the front seat with the airbag turned off"
4. "Icanturnbaby'scarseataroundwhensheweighs15pounds"
44. A nurse is assessing a client who has heart failure and is prescribed a 2.000mL / 24 hr fluid
restriction. Which of the following findings should the nurse report to the provider?
1. Waterystoolsof400mLin8hr???
2. Urinary output of 420 mL in 8 hr ****420 x 3= 1260 – 2,000 retaining 740 ml x day
3. Oral intake of 300 mL in 8 hr
4. Intravenousintakeof240mLin8hr
45. A nurse is caring for a client who is postoperative immediately following a cardiac
catheterization with a right femoral approach Which the following actions should the nurse
take?
1. Elevatetheheadoftheclient’sbedto450
2. Instructtheclienttoflextherightevery30min
3. Assess the client's peripheral pulses every 15 min
4. Changetheclient'sdressing4hrfollowingtheprocedure
46. A nurse is reviewing the cardiac rhythm of a client who is on continuous . Which of the
following findings should the nurse identify as an indication of
tachycardia?
1. QRScomplexeswiderthan0.15seconds
2. P-wave present with every QRS complex
3. PR interval of 0.24 seconds
4. SawtoothshapedPwaves
47. A nurse is providing teaching to a client who has multiple sclerosis. Which of the following
statements should the nurse include in the teaching?
1. "Establishavoidingschedulebyurinatingonceevery4hours"
2. "Limit your daily intake of high-fiber foods"
3. "Avoid exercises that increase your body temperature"
4. "Wearaneyepatchoveroneeyeforanentiredaybeforeswitching"
48. A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a
client. Which of the following statements should the nurse include the teaching?
1. "Youcanadjusttheamountofpainmedicationyoureceivebypushingonthekeypad."
2. "The PCA will deliver a double dose of medication when you push the button twice."
3. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels."
4. "Youshouldpushthebuttonbeforephysicalactivitytoallowmaximumpaincontrol."
49. A nurse realizes that the wrong medication has been administered to a client. Which of
the following actions should the nurse take first?
1. Filloutanincidentreport
2. Report the incident to the nurse manager
3. Measure the client's vital signs
ECG monitoring
ventricular
D. Notifytheprovider
50. A nurse is reviewing the facility's safety protocols concerning newborn abduction with the
parent of a newborn. Which of the following client statements indicates an understanding of
the teaching?
1. Staffwillapplyidentificationbandstomybabyafterherfirstbath.
2. "Iwillnotpublishapublicannouncementaboutmybaby'sbirth."
3. I can remove my baby's Identification band as long as she is in my room.
4. "IcanleavemybabyinmyroomwhileIwalkinthehallway
51. A nurse is assessing a client who immediately postoperative following a subtotal
thyroidectomy. The nurse observes tetany. Which of the following medications should the
nurse expect to administer?
1. Potassiumchloride
2. Sodium phosphate
3. Sodium bicarbonate
4. Calciumgluconate
52. A nurse is providing teaching to a client who is to begin external radiation therapy for
cancer. Which of the following Information should the nurse include?
1. Youmightexperiencealteredtastesensations
2. Wash your skin thoroughly with a washcloth after each treatment
3. Wear a binder over the radiation.
4. Userubbingalcoholtoremovetheinkmarkings.
53. A nurse is caring for a client who is 12 hr postoperative following aorta femoral bypass
surgery. Which of the following findings should the nurse expect in the affected extremity?
1. Coolextremities
2. Pedalpulseof2+
3. Throbbing pain
4. Capillaryof4seconds
54. 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?
1. Ensurethattheclient’sidentificationbandmatchesthenumberonthebloodunit.
2. Confirm the provider's prescription matches number on the blood component.
3. Match the client’s blood type with the type and cross match specimen.
4. Asktheclienttostatehisbloodtypeandthedateoftheblooddonation.
55. A nurse is teaching a community health fair about electrical fire prevention. Which of the
following information should the nurse include the teaching?
1. Coverextensioncordswitharug.
2. Remove the plug from the socket by pulling the cord.
3. Check for a tingling sensation around the cord to ensure the electricity working.
4. Usethree-prongedgroundedplugs.
56. A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive
crisis. Which of the following actions should the nurse take?
1. Promoteactiverangeofmotionexercise.
2. Prepare for a transfusion of platelets.
3. Increase oral fluid intake
4. Applycoldcompressestotheaffectedareas.
57. A nurse is caring for a client who has a history of depression and is experiencing a
situational crisis. Which of the following actions should the nurse take first?
1. Teachtheclientrelaxationtechniques.
2. Notify the client’s support person.
3. Confirm the client’s perception of the event.
4. Helptheclientidentifypersonalstrengths.
58. A nurse is caring for a client who has gestational hypertension and is experiencing toxic
effects due to magnesium sulfate therapy. The nurse should anticipate administering which of
the following medications?
1. Calciumgluconate
2. Magnesium citrate
3. Potassium chloride
4. Sodiumbicarbonate
59. A nurse is caring for a client who is in labor and . Which of
the following conditions should the nurse recognize as a to the use of
oxytocin?
1. Shoulderpresentation
2. Postterm with oligohydramnios ???
3. Chorioamnionitis
4. Diabetesmellitus
60. 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?
1. Limittheclient'svisitorsto30minperday
2. Discard the client's linens in a double bag.
3. Cleanse equipment before removal from the client's room.
4. Discardtheradioactivesourceinabiohazardbag.
requires augmentation of labor
contraindication
61. A nurse is caring for a client who has a prescription for 1 unit of after beginning the
transfusion, the client becomes
transfusion, which of the following actions should the nurse take?
A. Placethebloodbaginabiohazardbagbeforediscarding.
minutes . After stopping the
packed RBCs. Five
febrile with chills
2. Documentthereactioninthemedicalrecord.
3. Administer epinephrine subcutaneously.
4. Infuse500mLlactatedRinger'sIV. **onlyNormalsalineisusewithtransfusions
62. A nurse is providing teaching to a client who is breastfeeding and experiencing
engorgement. Which of the following recommendations should the nurse include?
1. Applywarmcompressesonthebreastsbeforefeedings.
2. Allow the infant to nurse on one breast per feeding,
3. Take aspirin to reduce pain and swelling.
4. Wearatight-fittingunderwirebra.
63. A nurse is providing teaching to the parent of a child who has a recently inserted central
venous access device. Which of the following statements by the child's family member
indicates an understanding of the teaching?
1. "Willreplacethedressingin24hourswithanocclusivedressing."
2. "Ifmychilddevelopsanelevatedtemperature.Iwillcontactyou."
3. "I can expect my child to resume playing sports within 48 hours."
4. "Ishouldencourageadailyshowertokeeptheinsertionsiteclean."
64. A nurse is caring for a client who tells the nurse that he feels he is being discharged from
the facility too soon. Which of the following state by the nurse demonstrates client advocacy?
1. "Iknowyouwillbeabletorecoverfasterathome."
2. "I will contact your insurance company to see if they will pay for you to be here longer."
3. "Your provider understands your illness and is acting according to your best interests."
4. "Iwilltelltheprovideraboutyourconcerns."
65. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the
following interventions should the nurse include in the plan of care?
1. Monitorthechildforindicationsofactivebleeding.
2. Prepare the child for a platelet transfusion. W
3. Screen the child's visitors for active infections.
4. Initiatealow-proteindietforthechild.
66. A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings is the priority for the nurse to report?
1. Chestpain
2. Cool, moist skin
3. Incisional pain
D. Musclespasms
67. 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?
1. "Riseslowlywhengettingoutofbed."
2. "Taking furosemide can cause you to be overhydrated."
3. "Eat foods that are high in sodium."
4. "Takingfurosemidecancauseyourpotassiumlevelstobehigh."
68. A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The
nurse should identify that which of the following statements by the client indicates an
understanding of the teaching?
1. "Iwillchangethewrappingonmyleftlegonceadayathome."
2. "I can elevate my left leg on a pillow while lying in bed."
3. "I should avoid moving the joints in my left leg."
4. "Imightstillexperiencethefeelingofnumbnessandtinglinginmyleftfoot."
69. A nurse is helping to prepare a client in the operating room prior to a surgical procedure.
Which of the following actions should the nurse take?
1. Minimizeconversationwiththeclienttoreduceanxiety.
2. Providepaddingtothepressurepointareaswhenpositioningtheclient.
3. Leave the client's arms and legs uncovered until after the induction of anesthesia.
4. Removetheclient'seyeglassesuponarrivaltotheoperatingroom.
70. A nurse is preparing to measure the temperature of an infant. Which of the following
actions should the nurse take?
1. Placethetipofthethermometerunderthecenteroftheinfant'saxilla.
2. Pull the pinna of the infant's ear forward before inserting the probe.
3. Insert the oral thermometer in front of the infant's tongue
4. Inserttheprobe3.8cm(1.5in)intotheinfant'srectum.
71. A nurse is assessing the grief response of a client whose child died 6 months ago. Which of
the following client statements should the nurse report to the provider as an indication of
major depressive disorder?
1. "Iamunabletofeelanyjoysincemychilddied."
2. "I am angry that my child died."
3. "know that I will be reunited with my child someday."
4. "Ifeelguiltybecausemychilddied."
72. A nurse is interviewing the partner of a client who was admitted in the manic phase of
bipolar disorder. The partner states. "I don't know what to do. Everything has been
happening so quickly." Which of the following responses by the nurse is therapeutic?
1. "Youdidtherightthingbybringingyourpartnerinfortreatment."
2. "You should make sure your partner takes the prescribed medication."
3. "Can you talk about what was happening with your partner at home?"
4. "Whydoyouthinkyourpartner'ssymptomsareprogressingsoquickly"
73. A nurse in a clinic is assessing a 6-month-old Infant. Which of the following findings should
the nurse report to the provider?
1. Closedanteriorfontanel **posterior-closesaround2months,anteriorat12-18mths
2. Pulse 140/min
3. Abdominal breathing
4. Respiratoryrate26/min
74. A nurse is caring for a client who is recovering from an
the elbow. Which of the following information should the nurse report to the occupational
therapist?
1. Theclientlivesinatwo-storyhome.
2. The client's parent is in a skilled nursing facility.
3. The client is allergic to penicillin
4. Theclienthastwosmallchildrenathome.
75. A nurse caring for a client who received a large amount of heparin IV in error. Which of
the following laboratory values should the nurse obtain?
1. Ferritinlevel
2. Albumin level
3. INR
4. aPTT
76. A nurse is performing an initial assessment of a newborn. Which of the following actions
should the nurse take to prevent any heat loss through conduction?
1. Evaluaterespirationsbyobservingthenewborn'suncoveredchestfor1min.
2. Cover the scale with a warmed blanket before weighing the baby.
3. Place the newborn's crib away from of an air vent to perform the assessment.
4. Performtheassessmentimmediatelyafterbirthbeforeremovingamnioticfluid.
76. A client's partner tells a staff nurse that he overheard laboratory staff discussing the
results of the client's biopsy report while on the elevator Which of the following actions
should the nurse take?
1. Reviewconfidentialitypolicieswithlaboratoryemployees.
2. Reporttheinformationtothechargenurse.
3. Contact the laboratory manager regarding the situation
4. Notifythefacility'slegaldepartment
amputation of her right arm below
77. A nurse is teaching a client who has chronic low back pain about the use of alternative
therapy to manage pain. Which of the following statements by the client indicates an
understanding of the use of distraction?
1. "Ishouldapplymyheatingblankettomybacktoreducetension."
2. "I will have electrodes inserted in my skin to treat the pain."
3. "I should jog every morning to improve my circulation."
4. "IwillwatchmyfavoriteoldmovieswhenIwanttoreducestress."
78. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the
following statements by the client indicates an understanding of the teaching?
1. "Iwillnotbeabletogoformydailywalk."
2. "I will cleanse my skin using a mild soap."
3. "I should apply powder to my skin after showering."
4. "Ishouldcheckmyskinonceweeklyforrashes."**needtobedonedaily
79. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of
the following statements by a client indicates an understanding of the teaching?
1. "Iwillconsume48ouncesofcarbonatedbeveragesdailypriortothesurgery."
2. "I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after
surgery."
3. "I will need to lose 25 percent of my excess body weight prior to surgery.
4. "Ishouldwait30minutesaftereatingsolidfoodstodrinkbeveragesfollowingsurgery."
80. 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. Iron
B. Calcium C. Folate D. Zinc
81. A nurse is caring for a client who is near the end of life and is on complete bed rest. The
client states that he needs to have a bowel movement. and the nurse offers a bed pan. The
client states. "I've always used the bathroom." Which of the following responses should the
nurse make?
1. "Iwillhavethephysicaltherapistambulateyoutothebathroom."
2. "You have to use the bed pan for your own safety."
3. "Make sure to use nearby furniture to support yourself when walking to the bathroom"
4. "Tellmewhatconcernsyouhaveaboutusingabedpan."
82. A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which
of the following findings should the nurse expect?
A. Increasedcalcium
2. Increased bicarbonate
3. Increased creatinine
4. Increasedhemoglobin
83. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary
catheter for three days. Which of the following actions should the nurse take after collecting
the specimen?
1. Placethespecimeninabiohazardbagfortransport.
2. Wipetheoutsideofthespecimencontainerwithanalcoholswab.
3. Obtain the specimen from the drainage collection bag.
4. Removeglovesafterlabelingthespecimen
84. 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?
1. Vaccinatesusceptiblechildrenandadultsagainstsmallpox.
2. Assess types, levels, and scopes of disasters.
3. Make quarantine preparations for those exposed to anthrax,
4. Participateincommunitydrillsandmockevents.
85. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse we use sterile gloves?
1. Performingtracheostomycare
2. Administering total parenteral nutrition through a central venous access device
3. Inserting an NG tube
4. InitiatingIVaccess
86. A charge nurse is recommending postpartum clients for discharge following a local
disaster. Which of the following clients should the nurse recommend for discharge first?
1. Aclientwhodeliveredprecipitously36hragoandhasasecond-degreeperineallaceration
2. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
3. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
4. A42-year-oldclientwhohaspreeclampsiaandaBPof166/110mmHg
87. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which
of the following findings should the nurse report to the provider?
1. Platelets150,000/mm3
2. Erythrocytesedimentationrate75mm/hr
3. Aspartate aminotransferase 10 units/L
4. WBCcount8,000/mm3
88. A nurse is discussing group treatment and therapy with a client. The nurse should include
which of the following as being a characteristic of a therapeutic group?
A. Thegroupencouragesclientstoformdependentrelationships.
2. The group encourages members to focus on a particular issue.
3. The group is organized in an autocratic structure.
4. Thegroupmustbeledbyalicensedpsychiatrist.
89. A nurse is providing teaching about home safety to the adult child of an older adult client
who is postoperative following knee replacement surgery. Which of the following instructions
should the nurse include?
1. Placeathrowrugoverelectricalcords.
2. Encourage the client to avoid wearing shoes at home,
3. Mark the edges of the doorway to the house with tape.???
4. Ensurethatarearugshaverubberbacks.
90. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings
indicates fluid overload?
1. Dyspnea
2. Thready pulse
3. Low-back pain
4. Hypotension
92. 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 both wrists. Which of
the following actions should the nurse take to address suspicions of elder abuse?
1. Contactthefamilyregardingtheclient'scondition
2. Inform the transferring agency of the client's condition.
3. Notify risk management.
4. Privatelyinterviewtheclientabouttheinjuries.
93. A nurse is providing discharge teaching to a client who has a new prescription for
phenelzine. The nurse should instruct the client that it is safe eat which of the following foods
while taking this medication?
1. Smokedsalmon
2. Pepperoni pizza
3. Whole grain bread
4. Avocados
94. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following
manifestations indicates and should be immediately reported to the provider?
A. Substernalretractions
B. Sneezing
C. Hematuria
D. Temperature37.9°C(100.2°F)
acute chest syndrome
95. 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?
1. Notifythenursingsupervisoraboutthesuspectedalcoholuse.
2. Inform another nurse on the unit about the suspected alcohol use.
3. Confront the nurse about the suspected alcohol use.
4. Askthenursetofinishadministeringmedicationsandthengohome.
96. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which
of the following actions should the nurse take?
1. Providefrequentstimulationforthenewborn.
2. Encourage frequent eye contact with the newborn during feedings
3. Wrap the newborn loosely in a blanket.
4. Decreasethelightinglevelsinthenursery.
97. A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which
of the following clients should the nurse instruct the AP to report to the nurse?
1. Aclientwhohasaprescriptionforcompressionstockingsanddidnotreceivethem
2. A client who consumes all the food from their meal tray
3. A client who requests assistance to use the bedside commode
4. AclientwhorequeststositinthebedsidechairwhilewatchingTV
98. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
1. "Dehydrationcanincreasetheriskforpretermlabor."
2. "Dehydration is treated with calcium supplements."
3. "Dehydration is associated with gastroesophageal reflux."
4. "Dehydration is caused by a decreased hemoglobin and hematocrit. *the contrary
increase
99. A nurse is preparing a change-of-shift report for an adult female client who is
postoperative. Which of the following client Information should the nurse include in the
report?
1. RBC4.4million/mm3
2. Hgb 12.8 g/dL
3. Platelets 100,000/mm ** normal 150,000- 400,000
4. Potassium4.2mEq/L
100. A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take?
A. Instructtheclienttolieonhisrightside.No-Intubate,ETtubestabilizer,Ltlateral,large bore, verify
placement, aspirate gastric content , use warm NSS, charcol.
B. Use a cold irrigation solution.
C. Insert a large bore NG tube.
D. Instill500mLofsolutionthroughtheNGtube.
101. A nurse is caring for a client who is experiencing acute mania. Which of the following
foods should the nurse provide for this clients?
1. Oatmealwithbutter
2. Peanutbuttersandwich
3. Celery sticks
4. Chickennoodlesoup
102. A nurse is providing discharge teaching to a female client who has tuberculosis and a
new prescription for rifampin. Which of the following information should the nurse include?
1. "Youshouldavoidsunexposurewhiletakingthismedication."
2. "You should avoid getting pregnant for 6 months after stopping this medication."
3. "Your urine will be orange while taking this medication."
4. "Weightgainisanexpectedadverseeffectofthismedication."
103. A nurse is preparing to initiate IV therapy for an older adult client. Which of the following
actions should the nurse plan to take?
1. Applyatourniquetfirmlyabovetheinsertionsite.
2. Usea22-gaugecatheterforinsertion???Thisiscorrect
3. Clean the site using vigorous friction.
4. Selectaveinonthebackofthehand.
104. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dL. Which of the
following manifestations should the nurse expect? Newborn BSL 40-50
1. Abdominaldistention
2. Hypertonia
3. Loose Stools
4. Jitteriness
105. A nurse is planning care for a client who is postoperative following a total hip
arthroplasty. Which of the following actions should the nurse plan to take when positioning
the client?
1. Flextheclient'shipupto120°whensittinginachair.
2. Maintain the client in a supine position for the first 24 hr after surgery.
3. Ensure that the client's hip remains in an abducted position.
4. Placetheclient'sheelsdirectlyagainstthebedmattress.
106. A nurse is reviewing legal issues in health care with a group of newly licensed nurses.
Which of the following recommendations should the nurse make?
A. Ensurethateachclienthasalivingwillonfilepriortotreatment.**notalwayspthasliving will
2. Overestimate clients' acuity to prevent short staffing.
3. Place copies of incident reports in clients' medical records.
4. Obtainpersonalprofessionalliabilityinsurancecoverage
107. A nurse is assessing a client who has bipolar disorder and is experiencing a depressive
episode. Which of the following findings should the nurse expect?
1. Clientexpressesillusionsofgrandeur
2. Inabilitytocarryoutasimpletask
3. Moves quickly from one idea to the next
4. Clientreportsauditoryhallucinations
108. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has
questions about the disease. To research the disease, the nurse should identify that which of
the following electronic databases has the most comprehensive collection of nursing journal
articles?
A. MEDLINE
B. CINAHL
C. ProQuest
D. HealthSource [Show Less]