The nurse performs an assessment on a full-term newborn. Which finding does the nurse report to the health care provider?
1. The client's blood pressure
... [Show More] of 70/44 mm Hg.
2. The umbilical cord is whitish gray in color.
3. Bowel sounds cannot be auscultated in the abdomen.
4. The big toe dorsiflexes when the side of the foot is stroked.
Ans: 3
2. The nurse in an antepartum clinic has several phone messages from clients. Which client does the nurse call first?
1. The client who is 10 weeks pregnant and reports vomiting after dinner for the past 5
days.
2 days.
2. The client who is 18 weeks pregnant and reports a headache in the evening for the past
3. The client who is 32 weeks pregnant and reports that her feet are swollen in the
morning.
4. The client who is 37 weeks pregnant and reports that her membranes have ruptured.
Ans: 4
3. The nurse prepares a medication in a prefilled syringe and notes that the syringe does not have a label with the client's name. What action will the nurse take?
1. Notify the pharmacy.
2. Call the health care provider.
3. Label the syringe.
4. Administer the medication.
Ans: 1
4. The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.)
1. Uncontrolled COPD can lead to cardiac disease.
2. Asthma in childhood leads to COPD later in life.
3. Cigarette smoking is the leading COPD risk factor.
4. More females are affected by COPD than males.
5. Co-existing illness may cause COPD exacerbation.
Ans: 1, 3,5
5. The nurse notes that a client requires protective isolation. Which additional client will the nurse safely pair with the client in protective isolation?
1. Client with a urinary tract infection.
2. Client with a stage 3 sacral pressure ulcer.
3. Client with unstable diabetes mellitus.
4. Client recovering from surgery for a perforated bowel.
Ans: 3
6. A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother?
1. Gestational diabetes.
2. A neural tube defects.
3. Trisomy 21 (Down syndrome).
4. Lack of lung maturity.
Ans: 1
7. The nurse notes that a toddler-age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next?
1. Document the findings in the chart.
2. Talk to the nursing supervisor.
3. Ask the client what happened.
4. Discuss the findings with the health care provider.
Ans: 1
8. The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct?
1. The National Council of State Boards of Nursing (NCSBN).
2. The American Nursing Association (ANA).
3. The Joint Commission.
4. The National League of Nursing (NLN).
Ans: 3
9. The nurse provides care for several clients. Which task does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.)
1. Determine client’s pain level.
2. Perform walker use training.
3. Assist with meal trays.
4. Bathe a client with wounds.
5. Obtain routine vital signs.
Ans: 3, 4, 5
10. A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided at 1000, at which time will the nurse schedule the peak level to be drawn?
1. 1100.
2. 1200.
3. 1400.
4. 1800.
Ans: 3
11. The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take?
1. Encourage strict bed rest.
2. Limit dietary fiber.
3. Encourage oral fluids.
4. Hold prescribed zoledronate.
Ans: 3
12. The nurse provides care for several clients in Buck traction. Which client is at greatest risk for skin breakdown?
1. An elderly client with severe Alzheimer disease.
2. An elderly client with a history of atrial fibrillation.
3. An elderly client with chronic bronchitis.
4. An elderly client with diverticulosis.
Ans: 1
13. The charge nurse reviews the medical records of several clients. Which documentation from a staff nurse requires the charge nurse to follow-up?
1. “Returned from radiology department following a chest X-ray. Requesting lunch but remains nothing by mouth until seen by the health care provider as prescribed.”
2. “Late – entry. Ambulated from bed to doorway without assistance. No shortness of breath or diaphoresis noted. Vital signs remained within baseline after ambulating.”
3. “Intravenous catheter site in left antecubital space is red and warm to touch. Intravenous solution infusing slowly. Catheter removed intact. New catheter placed in right forearm.”
4. “Found client sitting on floor. All four side rails were in upright position. Client reports no pain. No abrasions or bleeding noted. Health care provider notified. Incident report completed.”
Ans: 4
14. The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which statement provides the best information for the nurse to give when delegating this task?
1. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%."
2. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Report any readings outside the normal ranges."
3. “Please obtain blood pressure, heart rate, respiratory rate, temperature, pain rating, and pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), pain level >5/10, or pulse oximetry <95%."
4. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone’s blood pressure is <100 or >160, heart rate <50, respiratory rate <12, temperature >100.50F (45.60C), or pulse oximetry <93%."
Ans: 1
15. A client takes a beta 2 afrenergic agonist. Which finding indicates to mthe nurse that the client is experiencing and adverse reaction?
1. Drowsiness
2. Dysphagia
3. Palpitation
4. Paresthesias Ans: 3
16. The nurse notes that a client's laboratory values are blood urea nitrogen (BUN) 55 mg/dL (19.64 mmol/L) and creatinine 3.5 mg/dL (309.4 µmol/L). For which acid-base imbalance will the nurse assess the client?
1. Respiratory acidosis.
2. Respiratory alkalosis.
3. Metabolic acidosis.
4. Metabolic alkalosis.
Ans: 3
17. The nurse performs a nitrazine test on a client at 38 weeks' gestation. Which color change indicates that membranes have likely ruptured?
1. Yellow.
2. Olive-green.
3. Olive-yellow.
4. Blue green.
Ans: 4
18. A client develops ventricular tachycardia (VT). Which action does the nurse take next when providing care to this client?
1. Auscultate breath sounds.
2. Check pulse for a full minute.
3. Establish responsiveness.
4. Start cardiac compressions.
Ans: 3
19. The nurse notes that a client who follows Judaism has roast beef and whole milk on the dinner tray. Which action will the nurse take first?
1. Ask the nutrition department to replace the roast beef with pork.
2. Deliver the food tray to the client.
3. Ask the nutrition department for a new tray.
4. Replace the whole milk with skim milk.
Ans: 3
20. The nurse provides care for a client with face, ear, and neck burns. Which is the best position for the client?
1. Prone with a small pillow under the head.
2. Supine with padding on the affected side.
3. Supine without pillows or padding.
4. Prone without extra padding around the head.
Ans: 3
21. The nurse provides care for a client who requests testing for human immunodeficiency virus infection (HIV). Which intervention is most important for the nurse to perform before administering testing?
1. Discuss prevention practices to prevent the transmission of HIV to others.
2. Explain that all tests must be repeated twice to be valid.
3. Ask the client to identify all sexual partners.
4. Determine when the client thinks the exposure to HIV occurred.
Ans: 4
22. The nurse provides care to a client diagnosed with a clostridium difficile (C. diff) infection. Which precaution will the nurse take? (Select all that apply.)
1. Wear a protective gown when entering the client’s room.
2. Put on a particulate respirator mask when administering medications to the client.
3. Wear gloves when feeding the client a meal.
4. Ask the client’s visitors to wear a surgical mask when in the client’s room.
5. Wear sterile gloves when removing the client’s wound dressing.
Ans: 1, 3
23. The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication?
1. Twice a day within 1 hour before morning and evening meals.
2. Once a day before bedtime.
3. Twice a day within 2 hours before morning and evening meals.
4. Twice a day within 1 hour after morning and evening meals.
Ans: 1
24. The nurse provides care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding indicates that the treatment has been effective?
1. Serum osmolality is decreased.
2. Serum sodium is decreased.
3. Urinary output is increased.
4. Urine osmolality is increased.
Ans: 3
25. The nurse provides care for four clients. Which client will benefit the most from a multidisciplinary conference?
1. A 3-month-old client with intussusception who is vomiting, has colicky abdominal pain, and is having jelly-like stools.
2. A 2-month-old client with respiratory syncytial virus (RSV), who is wheezing and has moderate subcostal retractions and copious nasal discharge.
3. A 3-day-old client with developmental dysplasia of the hip, who has unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds.
4. A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant.
Ans: 4
26. The nurse provides care to a client who is unconscious. Which form of medication will the nurse safely administer to this client? (Select all that apply.)
1. Topical cream.
2. Subcutaneous injection.
3. Oral liquid.
4. Rectal suppository.
5. Intravenous infusion.
Ans: 1, 2, 4, 5
27. A client says, “I promise not to touch the intravenous catheter anymore because I don’t want to be slapped again.” Which action does the nurse take first?
1. Complete a neurological assessment.
2. Ask the nursing assistive personnel (NAP) if the client was slapped when providing care.
3. Ask the client where the slap occurred and under what conditions.
4. Document the client’s statement and report it to the nurse manager.
Ans: 3
28. The nurse provides care for a client who reports waking up with heartburn every night. Which client statement requires the nurse to provide further education to the client?
1. “I eat 3 meals a day.”
2. “I do not eat 2 hours before going to bed.”
3. “I will work on losing weight.”
4. “I will elevate the head of my bed 6 to 12 inches.”
Ans: 1
29. The nurse provides for a client who is being evaluated for possible thrombolytic therapy. Which lab value would cause the nurse the most concern?
1. Blood glucose of 160 mg/dL (8.88 mmol/L).
2. International normalized ratio (INR) of 1.2. 3. Platelets of 90,000/mm3 (90 X 109/L).
4. Hemoglobin of 9 g/dL (90 g/L).
Ans: 3
30. The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client?
1. Gloves.
2. Gown and gloves.
3. Gown, gloves, and mask.
4. Gown and gloves to change the linens; gloves when bathing.
Ans: 2
31. A client in her third trimester of pregnancy asks the nurse how to differentiate between true labor and false labor. Which is the best explanation by the nurse to describe false labor to the client?
1. The intensity, frequency, and duration of contractions do not change.
2. Discomfort begins in the back and radiates to the abdomen.
3. Contractions are accompanied by pink mucus from the vagina.
4. Progressive effacement and dilation of the cervix begin to occur.
Ans: 1
32. The nurse provides an older client, who was recently widowed, with a list of activities available at a local library. For which nursing diagnosis is this action most appropriate?
1. Risk for loneliness.
2. Risk for ineffective coping.
3. Risk for complicated grieving.
4. Risk for situational low self-esteem.
Ans: 1
33. The nurse provides care for a client that reports difficulty falling asleep several nights a week. The nurse reviews the client’s bedtime pattern. Which client statement requires an intervention by the nurse?
1. “I turn the TV off about an hour before bed and try to read.”
2. “I will go to bed when I am wide awake and relax in bed.”
3. “I will drink some herbal tea to help me wind down for the night.”
4. “I will limit my naps to 20 minutes a day.”
Ans: 2
34. The nurse prepares a client for surgery. Which task is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.)
1. Performing a clean catch urinalysis.
2. Collecting vital signs.
3. Monitoring lung sounds.
4. Applying compression stockings.
5. Educating on incentive spirometer use. Ans: 1, 2, 4
35. The nurse is teaching the parent of a 2-year-old client on how to correctly administer ear drops. Which action by the parent indicates to the nurse a need for further education?
1. Pulls the pinna up and back.
2. Directs the drops along the side of the ear canal.
3. Removes the ear drops from the fridge 30 minutes before giving.
4. Keeps the child lying down for 5 to 10 minutes before administering drops in the other
ear. Ans: 1
36. The nurse provides care to a client with severe hypothermia. Which assessment will the nurse perform first?
1. Determine presence of shivering.
2. Assess the skin for mottling.
3. Examine cardiac monitor for dysrhythmias.
4. Review laboratory values for a low calcium level.
Ans: 3
37. A client with transient confusion coughs constantly while being fed by nursing assistive personnel (NAP). Which action will the nurse take first?
1. Auscultate breath sounds.
2. Offer the client sips of water.
3. Direct the NAP to stop feeding the client.
4. Assess the oral cavity for pocketing of food.
Ans: 3
38. A client experiences a fever, headache, photophobia, and neck stiffness. Which transmission-based precaution will the nurse implement for this client?
1. Contact.
2. Airborne.
3. Droplet.
4. Standard.
Ans: 3
39. An older client with Medicare insurance asks the nurse to explain the “donut hole” in prescription drug coverage. Which response by the nurse is best?
1. It is a $20 co-payment for all prescriptions.
2. It is a temporary limit on what the drug plan will pay for covered drugs.
3. There is 20% decrease in prescription payment after six prescriptions per year.
4. There is no prescription drug coverage after age 85.
Ans: 2 [Show Less]