2 The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to
... [Show More] promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
a. A peanut butter sandwich with soda and cookies. b. A tuna fish sandwich with chips and ice cream.
c. Vegetable soup, crackers, and milk.
d. A salad with three kinds of lettuce and fruit.
3 The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center. Which outcome indicates that the program was effective?
A. Average client scores improved on specific risk factor knowledge test.
B. More than half of at-risk client were diagnosed early in their process.
C. New screening protocols were developed, validated, and implemented.
D. Clients who incurred disease complications promptly received rehabilitation.
4 A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessments include blood pressure 85/45 mm Hg, oral temperature 98.6° F (37° C), pulse 124 beats/minute, and respirations 22 breaths/minute. Based on these data, the nurse formulates the first portion of a nursing problem as "Risk for injury". What term best expresses the "related to" portion of the nursing problem?
a. head injury.
b. infection.
c. increased intracranial pressure. d. shock.
5 A nurse working on an endocrine unit should see which client first.
a. An adolescent male with diabetes who is arguing about his insulin dose.
b. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. d. A client taking corticosteroids who has become disoriented in the last two hours.
6 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement?
a. Transfuse Type A negative blood until Type AB negative is available.
b. Recheck the clienfs hemoglobin, blood type, and Rh factor.
c. Obtain additional consent for administration of Type A negative blood.
d. Administer normal saline solution until Type AB negative is available.
7 An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about the pets at home. Which interventions should the nurse implement? (Select au that apply.)
A- Evaluate pain using a standard pain scale
B- Alert social worker of client's concerns.
C- Support left leg with two pillows.
D- Palpate and mark pedal pulses.
E- Assess ability to bear weight when standing
8 Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider? (Click on the correct location on the chart. To change, click on a new location.)
▪ Serum Sodio 142 mEq/L (142 mmol/L)
▪ Postassium 3.9 mEq/L (3.9 mmol'/L)
▪ Serum glucose 62 mg/dl (3.4 mmdl/L)
▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L)
9 An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds,
and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?
a. Observe neck for jugular vein distention
b. Notify healthcare provider to prepare for pericardiocentesis
c. Asses for paradoxical blood pressure
d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry
10 The parent of a child born with a cleft lip asks the nurse to explain why this happened. The parent is concerned that they did something wrong that caused this to occur. Which response is most helpful?
a. "You didn't do anything wrong."
b. "This must be a very difficult time for you."
c. "With surgery, your baby should have a full recovery.
d. "Is there any particular reason why you think this is your fault?
11 After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?
a. Chest physiotherapy should be performed twice a day before a meal.
b. Administer a cough suppressant every 8 hours."
c. Energy should be conserved by scheduling minimally strenuous activities."
d. Maintain supplemental oxygen at 4 to 6 Uminute."
12 A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply.)
a. Auscultate bowel sounds in all quadrants.
b. Review last partial thromboplastin time results. c. Assess characteristics of pain.
d. Prepare to administer warfarin.
e. Monitor stools for presence of blood.
13 The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?
a. Literacy level.
b. Median age.
c. Prevalent learning style.
d. Percent with Internet access.
14 The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?
a. Gradual onset of continuous eye pain and blurred vision.
b. Recent change in the ability to read and drive after dark.
c. Gray-white circle around the iris of both eyes.
d. Cloudy opacity of the crystalline lens.
15 While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?
a. Inform the client that falls occur more often in the hospital than at home. b. Continue to obtain client data needed to complete the fall risk survey.
c. Record a minimal risk for falls, documenting the client's statement.
d. Place the client on a high fall risk protocol because of advanced age.
16 A client with gestational diabetes is being induced for labor. Which assessment is most important for the nurse to perform
prior to increasing the oxytocin rate? a. Contraction pattern.
b. Blood pressure.
c. Fingerstick glucose.
d. Vaginal exam.
17 A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dl (15 g/L). Which intervention is the priority for the nurse to implement?
a. Ensure the client receives frequent small meals containing complete proteins.
b. Recommend the use of support stockings to enhance venous return.
c. Evaluate patency of the AV graft for resumption of hemodialysis.
d. Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.
18
Following a motor vehicle collision (MVC), an unrestrained client is admitted to the intensive care unit with altered mental status. The client has multiple rib fractures and bruising across the lower abdomen. Which assessment finding warrants immediate intervention by the nurse? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)
a. A large amount of gross hematuria.
b. Several apnea episodes lasting ten seconds.
c. Delayed peripheral capillary refill.
d. Numbness of the left lower extremity.
19 Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia?
a. A client who developed hyperparathyroidism in late adolescence.
b. A female client who is overzealous with her intake of simple carbohydrates.
c. A middle-aged male client in renal failure following an unsuccessful kidney transplant. d. A young adult client with intractable vomiting from food poisoning.
20 An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)
a. Note date and time of the behavior
b. Discuss the issue privately with the UAP. R/ NDPE
c. Evaluate the UAP for signs of improvement.
d. Plan for scheduled break times.
21 The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which interventions should the nurse implement? (Select all that apply.)
a. Include the family in the discharge teaching. b. Face client when speaking.
c. Encourage the client to attend reading classes.
d. Speak loudly when teaching.
e. Provide the daughter with written instructions.
22 A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before
they get me." Which statement is the nurse's best response?
a. "You are in a safe place. No one can get to you here.
b. "There is no one who will hurt you."
c. "What would you like to see me do to protect you? d. "You seem quite frightened right now.
23 The nurse is caring for an adolescent who fell 20 feet (6.1 meters) 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?
a. Inquire about food allergies and food likes and dislikes. b. Talk directly to the adolescent while providing care.
c. Monitor vital signs and neuro status every 2 hours.
d. Initiate open communication with the teen’s parents.
24 In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on
diabetes self-management?
a. Prepare the client to independently treat their disease process
b. Reduce healthcare costs related to diabetic complications
c. Enable clients to become active participating in controlling the disease process
d. Increase client’s knowledge of the diabetic disease process and treatment options.
25 A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client requests an afternoon snack, which dietary choice should the nurse provide?
a. Vanilla-flavored yogurt
b. Low fat chocolate milk.
c. Calcium fortified juice d. Cinnamon applesauce
26 During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's left side. Which action should the nurse implement first?
a. Encourage the client to void.
b. Provide additional oral replacement fluids.
c. Massage the fundus until firm.
d. Catheterize for residual urinary volume.
27 A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm³. Which intervention should the nurse include in the client’s plan of care?
A. Monitor intake and output.
B. Pace activities between planned rest periods. C. Avoid intramuscular injections.
D. Limits exposure to visitors with respiratory infections.
28 When assessing a client, the nurse should establish which findings as objective? (Select all that apply.) a. Diaphoresis.
b. Edema.
c. Nausea. d. Urticaria.
e. Hypertension.
f. Anxiety.
29 The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?
a. Elevate the head of the bed to a 45-degree angle.
b. Remove dentures or other oral appliance.
c. Lift and lock the side rails in place.
d. Apply the client's positive airway pressure device.
30 The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? (Select all that apply.)
a. Sputum culture and sensitivity.
b. Serum potassium.
c. Red blood cell (RSC) count.
d. Blood urea nitrogen (BUN).
e. Urinalysis.
f. White blood cell (WBC) count.
31 A client arrives at the emergency department (ED) describing chest pain that began three hours earlier which has not subsided. To assess the quality of the client's chest pain, which approach should the nurse use?
a. Ask the client to describe the pain.
b. Provide a numeric pain scale.
c. Observe body language and movement.
d. Identify effective pain relief measures.
32 The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? (Select all that apply.)
a. Increased temperature. b. Increased pulse rate.
c. Peripheral pallor of the skin. d. Restlessness.
e. Increased respiratory rate. f. Clenched fists.
33 A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?
A. The impending signs of death should be documented.
B. The nurse manager should be update on the client’s status.
C. The client status should be conveyed to the chaplain.
D. The client’s need for pain medication should be determine.
34 An adult suffered burns to face and chest resulting from a grease fire. On admission, the client was intubated, and a 2- liter bolus of normal saline was administered IV. Currently the normal saline is infusing at 250 ml/hour. The client's heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H20. Which intervention should the nurse implement?
a. Infuse an additional bolus of normal saline.
b. Increase the oxygen delivered by the ventilator.
c. Lower head of the bed to a recumbent position.
d. Bring a tracheotomy tray to the bedside.
35 The nurse discovers that a male client has attempted suicide by slashing his wrists. What should the nurse do first?
a. Estimate the amount of blood loss.
b. Determine the depth of the slashes.
c. Check the client's level of consciousness.
d. Find the object used to cause the injuries.
36 A client was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, the client's urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?
a. Measure oral secretions suctioned during last 4 hours.
b. Obtain capillary blood samples for glucose every 2 hours.
c. Obtain blood pressure and assess for dependent edema.
d. Evaluate the urine osmolality and the serum osmolality values.
37 In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the
highest priority?
a. Risk for aspiration relative to muscle weakness.
b. Risk for constipation relative to immobility.
c. Self-care deficit relative to motor disturbance.
d. Impaired physical mobility relative to muscle rigidity.
38 A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?
A. Regression.
B. Compensation. C. Sublimation.
D. Suppression.
39 A 6-month-old infant is admitted to the hospital with diarrhea. The mother is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last 4 hours. Which laboratory finding is most important for the nurse to monitor?
A. Serum sodium levels.
B. White blood cell count.
C. Creatinine clearance.
D. Serum potassium levels.
40 A mother brings her 2-month-old infant to the clinic for a well-baby appointment. The nurse obtains a history and conducts physical assessment. Which finding requires the most immediate intervention?
A. Bilateral retinal hemorrhages.
B. Mother describes infant as irritable.
C. A positive Ortolani maneuver.
D. History of poor feeding and vomiting.
41 The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?
a. A 75-year-old client with renal calculi who requires urine straining.
b. A 64-year-old client who had a total hip replacement the previous day.
c. An adolescent with multiple contusions due to a fall that occurred 2 days ago. d. A 30-year-old depressed client who admits to suicide ideation.
42 One week after an above-the-knee amputation (AKA) of the left leg, a male client seems upset and reports that his left foot feels "numb." What action should the nurse implement?"
a. Assess right foot for signs of diminished circulation.
b. Offer assurance that the numb feeling is temporary. c. Reinforce learning about the cause of this sensation.
d. Assess wound for signs of inflammation or drainage.
43 A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission he begins to have a grand mal seizure. Which action should the nurse implement?
a. Call the rapid response team.
b. Place a padded tongue blade between client's teeth. c. Observe the client carefully.
d. Obtain assistance in holding him to prevent injury.
44 The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of “Ineffective airway clearance related to thick pulmonary secretions.” Which intervention is most important for the nurse to include in the client’s plan of care?
a. Increase fluid intake to 3,000 ml/daily
b. Maintain the client in a semi-Fowler's position.
c. Administer 02 at 5 Minutes per nasal cannula.
d. Provide frequent rest periods.
45 Two weeks post-burn, a male client with 40% deep partial-thickness injury continues to have open wounds and is now developing diarrhea. His blood pressure is 80/40 mmHg and his temperature is 96°F (35.6°C). Which action is most important for the nurse to take?
A. Increased the room temperature.
B. Assess the oxygen saturation. C. Notify the rapid response team.
D. Continue to monitor vital sings.
46 The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which
characteristics? Select all that apply
a. Written at a twelfth-grade reading level
b. Printed using a 12-point type font
c. Contains a list with definitions of unfamiliar terms d. Uses common words with few Syllables
e. Uses pictures to help illustrate complex ideas
47 A client with generalize anxiety disorder does not want to communicate with friends, smokes 2to 3 packages of cigarettes a day, and describe difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?
A. Analyze past hurts and resentments to identify the source.
B. Concentrate on and ventilate emotions when distressed.
C. Relax and reduce the amount of effort to solve the problem.
D. Focus on small achievable tasks, not taxing problems.
48 A client who has a right subclavian vein central venous (CV) catheter transducing continuous central venous pressures (CVP) reports the return of midsternal chest pressure. The client receives prescriptions for a STAT 12-lead electrocardiogram and troponin level. While the nurse withdraws blood from the CV catheter, the bedside monitor begins to alarm. Which factor should nurse first suspect is causing the monitor to alarm?
a. Blood in the CV line.
b. Lethal cardiac rhythm.
c. Air in the CV line.
d. Loss of CVP waveform.
49 A client with advanced cirrhosis is being treated for hepatic encephalopathy. In reviewing the client's serum laboratory results, which finding requires the most immediate intervention by the nurse?
a. Lowered total protein and albumin.
b. Elevated direct bilirubin.
c. Decreased ammonia.
d. Prolonged prothrombin time (PT).
50 Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?
a. Pallor.
b. Orthopnea.
c. Right-sided paralysis.
d. 2+ pitting edema of the feet.
51 An older client whit a 3-day history of abdominal distention is admitted with a small bowel obstruction. The nurse inserts a nasogastric tube and attaches it to low intermittent suction. Which ongoing client assessment takes priority when providing care?
A. Measure abdominal girth.
B. Observe skin integrity.
C. Auscultate bowel sounds.
D. Monitor fluid balance.
52 During a return demonstration of teaching provided by the nurse, the daughter of a client administers her mother’s eye drops by resting her dominant hand on her mother’s forehead and dropping the medication into the conjunctival sac. Which action should the nurse take in response to this demonstration?
A. Offer to demonstrate the eye drop procedure to the daughter one more time.
B. Instruct the mother to gently rub the affected eye to distribute the drops. C. Remind the client to gently close her eyes after the eye drops are instilled.
D. Advice the daughter to keep her hand farther from her mother’s eye.
53 A middle-age male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based in this client age and recent life-threatening crisis, which intervention is should the nurse implement?
A. Provide a routine schedule of activities to facilitate trust.
B. Allow long periods of uninterrupted rest in order to reduce fatigue.
C. Discuss the cause of the accident with the client and his family. D. Encourage the client to reflect on personal goals and priorities.
54 During a fecal impaction removal, an older client complains of feeling dizzy and cold. What intervention should the nurse implement?
a. Instruct the UAP to apply a warm blanket and massage the client's back.
b. Stop the procedure and observe for a reduction in symptoms before continuing.
c. Insert a gloved finger into the rectum and gently massage the rectal sphincter.
d. Encourage the client to take slow, deep breaths while continuing the procedure.
55 A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?
a. Engage the client in a game of cards.
b. Complete an assessment of social support.
c. Encourage the client to have lunch off the unit.
d. Give the client a schedule of planned daily activities.
56 Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?
a. Begin postoperative prophylactic antibiotics.
b. Administer an antiemetic to prevent vomiting.
c. Report the complaint of eye pain to the surgeon.
d. Apply bilateral eye shields to reduce photosensitivity.
57 A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
a. Conversion of the client’s PPD test from negative to positive.
b. Length of time of the exposure to tuberculosis. c. Current diagnosis of hepatitis B.
d. History of intravenous drug abuse.
58 An older adult client is diagnosed with severe shingles and starts a new prescription for acyclovir, an antiviral medication. Which action should the nurse include during client teaching prior to discharge?
a. Schedule an appointment for medication peak and trough levels.
b. Demonstrate how to apply sterile gauze dressings over the infected site.
c. Explain the increased risk for postherpetic neuralgia during treatment. d. Encourage increased oral fluid intake while taking the medication.
59 Locate the macula and fovea centralis. (Click the chosen location. To change, click on the new location.) [Show Less]