1. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the
head of the bed 30 degrees. What is the reason for
... [Show More] this intervention?
To reduce abdominal pressure on the diaphragm
to promote retraction of the intercostal accessory muscle of respiration
to promote bronchodilation and effective airway clearance
to decrease pressure on the medullary center which stimulates breathing
Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for
decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.
2. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the
gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal
muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?
The client is too obese
Palpating in the wrong abdominal quadrant
Deeper palpation technique is needed
The gallbladder is normal
Rationale: a normal healthy gallbladder is not palpable
3. A woman with an anxiety disorder calls her obstetrician‘s office and tells the nurse of increased
anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she
stopped taking her antianxiety medications, but thinks she may need to start taking them again
because of her increased anxiety. What response is best for the nurse to provide this woman?
Describe the transmission of drugs to the infant through breast milk
Encourage her to use stress relieving alternatives, such as deep breathing exercises
Explain that anxiety is a normal response for the mother of a 3-week-old.
Inform her that some antianxiety medications are safe to take while breastfeeding
Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers.
4. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives
at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and
cannot remember when he took his last dose of insulin or ate last. What action should the nurse
implement first?
Start an intravenous (IV) infusion of normal saline
obtain a serum potassium level
administer the client's usual dose of insulin
assess pupillary response to light
Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and
electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The
symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia,
which also contributes to diuresis and fluid electrolyte imbalance.
5. A client who received multiple antihypertensive medications experiences syncope due to a drop in
blood pressure to 70/40. What is the rationale for the nurse‘s decision to hold the client‘s scheduled
antihypertensive medication?
increased urinary clearance of the multiple medications has produced diuresis and lowered
the blood pressure
the antagonistic interaction among the various blood pressure medications has reduced their
effectiveness
the synergistic effect of the multiple medications has resulted in drug toxicity and resulting
hypotension
The additive effect of multiple medications has caused the blood pressure to drop too
low
6. Which client is at the greatest risk for developing delirium?
An adult client who cannot sleep due to constant pain.
an older client who attempted 1 month ago
a young adult who takes antipsychotic medications twice a day
a middle-aged woman who uses a tank for supplemental oxygen
7. Which intervention should the nurse include in a long-term plan of care for a client with Chronic
Obstructive Pulmonary Disease (COPD)?
Reduce risks factors for infection
Administer high flow oxygen during sleep
Limit fluid intake to reduce secretions
Use diaphragmatic breathing to achieve better exhalation
8. Which location should the nurse choose as the best for beginning a screening program for
hypothyroidism?
A business and professional women‘s group
An African-American senior citizens center
A daycare center in a Hispanic neighborhood
An after-school center for Native-American teens
9. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After
stopping the medication abruptly, the client reports feeling ―very tired‖. Which nursing intervention
is most important for the nurse to implement?
Auscultate breath sounds
Palpate the abdomen
Measure Vital signs
Observe the skin for bruising
10. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab
is important for the nurse to review before contacting the health care provider?
capillary glucose
urine specific gravity
Serum calcium
white blood cell count
11. What explanation is best for the nurse to provide a client who asks the purpose of using the logrolling technique for turning?
working together can decrease the risk for back injury
The technique is intended to maintain straight spinal alignment.
Using two or three people increases client safety.
turning instead of pulling reduces the likelihood of skin damage
12. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to
recommend to the client?
• Baked apples topped with dried raisins
13. Which action should the school nurse take first when conducting a screening for scoliosis?
• Inspect for symmetrical shoulder height.
14. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse
that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse
implement?
• Assign a practical nurse (LPN) to determine if an apical radial deficit is present
15. After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate
that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was
recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is
more important to include in this client‘s discharge plan?
Encourage a low-carbohydrate and high-protein diet
16. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is
most important for the nurse to perform?
• Observe the antecubital fossa for inflammation.
17. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the
medication‘s effectiveness, which laboratory values should the nurse monitor? (Select all that apply)
White blood cell count
Sputum culture and sensitivity
18. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control
measures should the nurse implement?
Negative pressure environment
contact precautions
droplet precautions
protective environment
19. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up
action by the nurse?
• Review with the client the need to avoid foods that are rich in milk and cream
20. A male client with hypertension, who received new antihypertensive prescriptions at his last visit
returnsto the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits
that he has not been taking the prescribed medication because the drugs make him ―feel bad‖. In
explaining the need for hypertension control, the nurse should stress that an elevated BP places the client
at risk for whichpathophysiological condition?
• Stroke secondary to hemorrhage [Show Less]