NCLEX-RN EXAM 2020 -
1. Which of the following signs or symptoms indicates a possible nutritional deficiency?
Pale conjunctiva
2. A nurse is
... [Show More] preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?
From the tip of the nose to the earlobe to the xiphoid process
3. In which of the following ways can a nurse promote sleep for a client who is experiencing insomnia?
Give the client a pair of socks to wear if his feet become cold
4. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:
Radiating pain
5. A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is:
Hesitancy
6. A nurse is preparing to irrigate a client's colostomy. Which of the following situations is a contraindication for this type of irrigation?
The client has diverticulitis
7. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?
The client was found lying on the floor.
8. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
Transport the victim to the operating room for surgery.
9. Which of the following statements best describes substance P?
Substance P is found in the dorsal horn of the spinal column
10. The primary purpose of a patient care meeting or conference is to determine which of the following?
How the healthcare team can best meet the patient's needs.
11. Who should be members of a patient care conference?
ALL members of the healthcare team and the patient/resident.
12. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
Reassess the client.
13. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?
Clarify with the team leader to make a safe ICU client assignment.
14. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co- worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
Call the nursing supervisor.
15. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your request."
16. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.
i. Document the correct information and end with the nurse's signature and title.
ii. Draw 1 line through the error, initialing and dating it.
17. Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?
Only the health care proxy
18. Which of the following is an example of physical abuse?
A slap to the person's hand
19. Which of the following is an example of emotional abuse?
Threatening the person
20. Which of the following is an example of emotional neglect?
Ignoring and isolating a person
21. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit?
10% dextrose in water
22. The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take?
Ensure that the fat emulsion infusion rate is infusing at the prescribed rate
23. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?
Crackles on auscultation of the lungs
24. The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?
Secure all connections in the PN system.
25. A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?
Hypervolemia
26. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
Slow the IV infusion.
27. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first?
Check compatibility of the medication and IV fluids.
28. The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank.
375ml
29. Patients have a right to .
ALL of their health related information
30. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have
Seriously abandoned the patients
31. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat so a nurse force feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed against this patient.
Battery
32. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?
Observe the patient for any injuries and call out for help.
33. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?
The chest pain
34. Which identifies accurate nursing documentation notations? Select all that apply.
i. The client slept through the night.
ii. Abdominal wound dressing is dry and intact without drainage.
iii. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
35. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?
Observing care provided to the client without the client's permission
36. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort?
Slander
37. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care is the lowest in terms of priority?
The crying person
38. You are caring for Mrs. Thomas. You see a notation on the nursing care plan that states "ambulate at least 10 yards qid". This patient will be assisted with ambulation at which of the following times?
10 am, 2 pm, 6 pm and 10 pm
39. The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?
Oranges and dark green leafy vegetables
40. The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high- fat foods to avoid and should include which food items on the list? Select all that apply.
i. Margarine
ii. Cream cheese
iii. Luncheon meats
41. The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?
Cream of wheat, blueberries, coffee
42. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?
Vitamin B12
43. A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?
Summer squash
44. A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.
i. Broth
ii. Coffee
iii. Gelatin
45. The supervising RN asks you to bring the unit's collected lab specimens to the lab "stat". You should .
Run this errand immediately and without delay.
46. You are working the 4 pm to 12 midnight evening shift. You are taking care of a group of patients. The supervising RN identifies 5 patients who get a medication at "HS". When will you give this medication?
At the patient's bedtime
47. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
48. The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?
Contact the nursing supervisor.
49. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?
Call the nursing supervisor and report the incident.
50. You are caring for Mr. Charles Y. You see a notation on the nursing care plan that states, "remind the patient to use the incentive spirometer tid". This patient will be reminded at which of the following times?
10 am, 2 pm and 6 pm
51. A nursing care plan states, "Assist the patient to the bedside commode prn". When will this patient get this assistance to the commode?
Whenever needed
52. You see a sign over Mary Jones' bed when you arrive at 7 am to begin your day shift. The sign says, "NPO". Ms. Jones is on a regular diet. The patient asks for milk and some crackers. You .
Cannot give her anything to eat or drink.
53. Match the abbreviation with the correct definition:
Ac: before meals
54. The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?
Answers-Continue with the instructions, verifying client understanding.
55. A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
i. Answers-Ensures that a close relative stays with the client
ii. Makes a referral for a Catholic priest to visit the client
iii. Offers to provide a means for praying the rosary if the client wishes.
56. Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5)
i. Latino American Man
ii. Native American man
iii. Hispanic American man
iv. African American woman
57. The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?
"I cannot have any food containing or prepared with blood."
58. The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
Reflecting a cultural value
59. When communicating with a client who speaks a different language, which best practice should the nurse implement?
Arrange for an interpreter to translate.
60. Which is NOT an acceptable abbreviation?
D/C
61. You are taking Mr. D's blood pressure. The first sound that you hear is at 162 and the second sound that you hear is at 86. You should document and report that the blood pressure is .
162/86
62. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?
Preventing and recognizing hyperglycemia
63. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?
2000 mm3 (2.0 × 109/L)
64. A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
65. The nurse is caring for a postoperative client who is receiving demand- dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?
Attempt to arouse the client.
66. An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?
Iron deficiency anemia
67. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?
The specimen should be stored in an area protected from light.
68. Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?
One lavender, one grey
69. Specific gravity in urinalysis:
Compares the concentration of urine to that of distilled water.
70. The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?
"I need to restrict my activity while this catheter is in place."
71. A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour?
Chest radiology results
72. Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?
Crackles in the lungs
73. When placing a patient in the AP position for an X-ray, what position would the patient be in?
Facing away from the film.
74. A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
Run a Clinitest.
75. An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method?
Foods considered to be yin
76. Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?
Sweet and sour chicken with rice and vegetables, mixed fruit, juice.
77. Which is the best nursing intervention regarding complementary and alternative medicine?
Educating the client about therapies that he or she is using or is interested in using
78. An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?
Encourage the client to discuss the use of an herbal substance with the health care provider (HCP).
79. The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?
"Magnetic therapy and massage therapy are a focus of CAM."
80. A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?
Infertility
81. Manual hematocrits are done:
a. to monitor anemia.
b. by using a microcrit tube.
c. to measure the percentage of plasma to cells.
All of the above.
82. The BEST blood collection location for a newborn is:
The heel.
83. A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
15 mg/dL (5.25 mmol/L)
84. The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?
Taking an oral temperature for a client with a cough and nasal congestion
85. A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?
3.2 mEq/L (3.2 mmol/L)
86. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.
i. Platelets 35,000 mm3 (35 × 109/L)
ii. Sodium 150 mEq/L (150 mmol/L)
iii. Segmented neutrophils 40% (0.40)
iv. White blood cells, 3000 mm3 (3.0 × 109/L)
87. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply.
i. Warfarin
ii. Glimepiride
iii. Amlodipine
88. A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?
Perform the procedure but pay close attention for signs of potential syncope.
89. Which of the following tests would MOST LIKELY be performed on a patient that is being monitored for coagulation therapy?
PT/INR
90. Which of the following is MOST TRUE about the ESR test?
Abnormal results should be followed with additional testing.
91. The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?
Blood return shows in the backflash chamber of the catheter.
92. The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?
Remove the IV site and restart at another site.
93. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?
Obtain new IV tubing
94. A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?
Sterile 2 × 2 gauze
95. A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.
i. Remove the IV catheter at that site.
ii. Apply warm moist packs to the site.
iii. Notify the health care provider (HCP).
iv. Document the occurrence, actions taken, and the client's response.
96. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client?
5% dextrose in lactated Ringer's solution
97. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
Septicemia
98. A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
Contact the physician to amend the order for the client
99. A nurse is at the beginning of her shift in a long-term care facility. Which of the following clients should she check on first?
An 82-year old woman who needs IV antibiotics
100. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following people would be most appropriate to be transferred to this unit?
A 26-year old woman who had a bowel resection
101. A nurse in the emergency room enters a client's care area to start an IV. She finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, "My chest hurts so much!" His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the nurse?
Assess his breathing and provide oxygen, if necessary
102. Examples of preservation of self-integrity include all of the following except:
Accepting the challenge of caring for clients with oppositional beliefs or practices
103. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?
An increased pH and an increased HCO –
104. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3– = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?
The client is probably hyperventilating.
105. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.
i. Respirations that are increased in rate
ii. Respirations that are abnormally deep
106. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3– is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?
Respiratory acidosis without compensation
107. The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.
a. Nausea
b. Confusion
c. Tachycardia
d. Lightheadedness
108. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?
pH 7.25, Paco2 50 mm Hg (50 mm Hg)
109. The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
Potassium level of 3.0 mEq/L (3.0 mmol/L)
110. Which method best describes the use of evidence-based practice?
Using the most effective, current, and applicable information available to guide nursing care for the best of the clients.
111. A public health nurse discovers that many of the children in the neighborhood where she works are developing lead toxicity. She implements a program to screen for lead exposures among clients in the community. This is an example of:
Social justice
112. Which of the following is an example of whistle blowing?
A nurse contacts administration about a colleague who takes supplies to use for a mission trip
113. A nurse is caring for a client who has a right-sided chest tube. The chest tube shows 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. Which action is most appropriate of the nurse at this time?
Place a clamp on the tube near the client's chest
114. A nurse is caring for a client with a broken femur who is in a traction splint in bed. All of the following interventions are part of care of this client EXCEPT:
Turning the client to a side-lying position
115. A nurse is assessing a client with right-sided heart failure. Which of the following symptoms would the nurse most likely see in this client?
Coughing and 3+ pitting edema
116. A nurse is educating a client about her cholesterol. Which of the following statements from the client indicates the need for further teaching?
It is better for me to have high LDL levels and low HDL levels."
117. A nurse is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:
Clean the cap with alcohol and attach a 5 cc syringe
118. Which of the following situations might warrant a laboratory magnesium level?
Ulcerative colitis
119. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?
Administer corticosteroids as ordered
120. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
External light sources may cause falsely high oximetry values
121. A nurse is educating a client who is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
Collect the stool from the toilet after having a bowel movement
122. A nurse is caring for a client who must use a non-rebreathing oxygen mask. Which of the following statements is true regarding this type of mask?
A non-rebreather offers a reservoir from which the client inhales.
123. A client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?
A fever that spikes and then lowers without returning to normal
124. A local sign of infection is which of the following?
Swelling.
125. A systemic sign of infection is .
A lack of appetite
126. Mobility is an important human function. The hazards of immobility lead to many physical problems and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin and emotional changes. Which of the following is an example of a skeletal hazard of immobility?
Calcium loss.
127. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
Hypotriglyceridemia
128. A nurse is assisting Mr. L, a client who has a new colostomy after a bowel resection. The nurse is teaching this client how to care for his colostomy bag. Which of the following statements from Mr. L indicates the need for more education?
I need to wait ½ hour after I irrigate to replace the colostomy bag."
129. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?
Stage II
130. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?
Wear a mask if coming within 3 feet of the client [Show Less]