A nurse is assessing a client who has received an antibiotic. The nurse should identify which of the
following findings as an indication of a possible
... [Show More] allergic reaction to the medication?
A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing
auditory hallucinations telling them to hurt others. The client is refusing to take anti-psychotic
medication. Which of the following responses should the nurse make?
A nurse is providing care for a patient who has depression and isto have electroconvulsive therapy.
Which of the following conditions should the nurse identify as increasing the client’s risk for
complications?
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?
A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an
endotracheal tube. Which of the following findings should the nurse identify as an indication that
suctioning has been effective?
A nurse is caring for a client who is in a seclusion room following violent behavior. The client
continuesto display aggressive behavior. Which of the following actionsshould the nurse take?
A nurse is caring for a client who isimmediately postoperative following an adrenalectomy to treat
Cushing’s disease. Which of the following actions is the nurse’s priority?
A nurse is evaluating a client who has borderline personality disorder. Which of the following
behaviors indicates an improvement in the client’s condition?
A. Impulsive behaviors
B. Decreased clinging behavior
C. Liability of mood
D. Dependent behavior
A nurse is teaching a group ofschool-age children about healthy snack options. Which of the
following snacks should the nurse include?
A. Air-popped popcorn
B. Milkshake made with whole milk.
C. Baked potato chips
D. Cheesecake
11. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the
following medications for pain relief should the nurse include in the teaching that can be taken
concurrently with enoxaparin?
A. Naproxen sodium
B. Ibuprofen
C. Acetaminophen
D. Aspirin
12. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the
following medications should the nurse plan to administer?
A. Colchicine
B. Lorazepam
C. Pregabalin
D. Codeine
13. A nurse is caring for a client who has congestive heart failure and is receiving furosemide and
digoxin. Which of the following laboratory valuesindicatesthat the client is at risk for developing
digoxin toxicity?
A. Glucose 150 mg/dL
B. Magnesium 1.3 mEq/L
C. Potassium 3.1 mEq/L
D. Sodium 134 mEq/L
14. A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of
the following in the client’s history should the nurse identify as a contraindication for receiving
alteplase?
A. Hip arthroplasty 1 week ago correct
B. Obstructive lungs disease
C. Retinal detachment
D. Acute kidney failure 6 months ago
15. A nurse is providing discharge teaching for a client who has a new implantable cardioverter
defibrillator(ICD). Which ofthe following clientstatements demonstrates understanding of the
teaching?
A. “I willsoak in the tub rather than showering.”
B. “I can holdmy cellphone on the same side of my body as the ICD.”
C. “I will wear loose clothing over my ICD.”
D. “I will avoid using my microwave oven at home because of my ICD.”
16. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling
urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions
should the nurse anticipate?
A. Clamp the catheter tubing for 30 min
B. Initiate continuous bladderirrigation
C. Obtain a urine specimen for culture and sensitivity
D. Administer a fluid bolus
17. A nurse is caring for a client who has experienced a stillbirth. Which of the following actionsshould
the nurse take during the initial grieving process?
A. Avoid talking to the client about the newborn
B. Discourage the client from allowing friendsto see the newborn
C. Offer to take pictures ofthe newborn for the client
D. Assure the client that she can have additional children
18. A nurse is caring for a client who has a major burn injury. Which of the following actions is the
nurse’s priority to prevent wound infection?
A. Use sterile dressings for wound care
B. Apply topical antibiotics to the client’s wounds.
C. Place the client in protective isolation.
D. Maintain consistent hand washing by staff.
19. A nurse is speaking with the caregiver of a client who has Alzheimer’s disease. The caregiver states,
“Providing constant care is very stressful and is affecting all areas of my life.” Which of the following
actions should the nurse take?
A. Discussmethods of how to communicate with the client about problem solving behaviors.
B. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
C. Assist the caregiver to arrange a daycare program for the client.
D. Recommend allowing the client to have time alone in their room throughout the day.
20. A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following
actions should the nurse take?
A. Administer a benzodiazepine
B. Perform a fundal massage
C. Place an ice pack on the client’s perineum
D. Place the client’s hand in warm water
21. A nurse on amedical-surgical unit is performing medication reconciliation for a newly admitted
client. Which of the following actions should the nurse take?
A. Compare a list of common medicationsto treat a condition to the actual prescriptions
B. Compare the prescription to the allergy history of the client
C. Compare the medication label to the provider’s prescription on three occasions before
administration
D. Compare the client’slist of home medicationsto the admission prescriptions written for the
client.
22. A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has
preterm labor. Which of the following findings should the nurse identify as an adverse effect of this
medication?
A. Hyperglycemia
B. Uterine contractions
C. Proteinuria
D. Hypotension
23. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which
of the following actions should the nurse take? (SATA)
A. Apply a tourniquet above the catheter insertion site.
B. Accessthe catheter using a large bore needle.
C. Aspirate for blood return to access catheter patency.
D. Flush the catheter with 0.9% sodium chloride.
E. Apply force when resistance is met while flushing the catheter.
24. A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions
should the nurse take to prepare the child for the procedure?
A. Explain in simple terms how the procedure will affect the child.
B. Ask the parentsto wait outside the room during the procedure.
C. Limit teaching sessions about the procedure to 20 min.
D. Instruct the child in deep-breathing methods prior to the procedure.
25. A nurse is performing wound care for a client who has an abdominal incision. Which of the following
techniques should the nurse implement?
A. Irrigate the wound using a 10-mL syringe.
B. Cleanse the wound starting at the bottom and moving upward.
C. Cleanse the insertion site of the drain using a circularmotion towardsthe center.
D. Irrigate the wound with a low-pressure flow of solution.
26. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients
should the nurse see first?
A. A client who is at 36 weeks of gestation and has a biophysical profile score of 8.
B. A client who has preeclampsia and reports a persistent headache.
C. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%.
D. A client who is at 28 weeks of gestation and reports leukorrhea.
27. A nurse is caring for a client who isrecovering from an amputation of her right arm above the elbow.
Which of the following information should the nurse report the occupational therapist?
A. The client’s parent is in a skilled nursing facility.
B. The client has two small children at home.
C. The client is allergic to penicillin.
D. The client lives in a two-story home.
28. A nurse is caring for a client who has major depressive disorder. The client tellsthe nurse, “No one
cares about me. I’m completely alone.” Which of the following responsesshould the nurse make?
A. “You should join a community support group.”
B. “What makes you think that?”
C. “Don’t worry. You should be feeling better in a couple weeks.”
D. “Can you give me an example of how others are making you feel this way?”
29. A nurse is caring for a client who hassustained a severe head trauma and hassignificant bleeding
from the nose. Which of the following actions should the nurse take first?
A. Prepare for a CT scan.
B. Insert a peripheral IV line.
C. Establish a patent airway.
D. Apply direct pressure to the nose.
30. A nurse is reviewing the rhythm strip of a client who is experiencing sinus arrhythmia. Which of the
following findings should the nurse expect?
A. Inconsistent P wave formation.
B. Ventricular and atrial rates 120/min
C. P-R intervals of 0.30 seconds
D. P to QRS ratio 1:1 page 720 Med surg book
31. A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse
that she lived in this facility years ago and took care of all the residents by herself. The nurse should
document this as which of the following findings?
A. Confabulation
B. Agnosia
C. Projection
D. Perseveration
32. A nurse isreviewing home recommendations with a client who is postoperative following knee
surgery. Which of the following recommendations should the nurse make?
A. Place a handrail in the entryway of the house.
B. Place a towel on the floor outside of the shower.
C. Ensure that all area rugs are rubber-backed.
D. Wearslippers with cloth soles.
33. A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the
following actions should the nurse take to prevent dislocation of the prosthesis?
A. Raise the head of the client’s bed to a high-fowler’s position.
B. Elevate the client’s effected leg on a pillow when in bed.
C. Position the client’s knees slightly higher than the hips when up in a chair.
D. Keep an abduction pillow between the client’s legs.
34. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster virus. Which of
the following information should the nurse include?
A. Children who have varicella should be placed on droplet precautions.
B. Children who have varicella are contagious 4 days before the first vesicle eruption.
C. Children who have varicella are contagious until the vesicles are crusted.
D. Children who have varicella should receive the herpes zoster vaccine.
35. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take?
A. Teach the client how tomeditate
B. Sit with the client to provide a sense ofsecurity.
C. Encourage the client to watch television.
D. Administer a dose of atomoxetine to decrease anxiety.
36. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following
actions by the newly licensed nurse indicates an understanding of the teaching?
A. Stands with feet together when lifting a client up in bed.
B. Places a gait belt around the client’s upper chest before assisting a client to stand.
C. Uses a mechanical lif t device to move a client from the bed to the chair.
D. Raises the client’s head of the bed before pulling the client up.
37. A nurse is teaching a client about condom use. Which of the following client statementsshould the
nurse identify as an understanding of the teaching?
A. “I can use petroleum jelly as a lubricant with the condom.”
B. “I can re-use the condom one time after initial use.”
C. “I can use natural-skin condomsto preventsexually transmitted infections.”
D. “I can store the condoms in the drawer of my night-stand.”
38. A nurse is planning care for a client who has a chest tube. Which of the following interventions
should the nurse include in the plan? (SATA)
A. Maintain the collection chamber above the level of the client’s waist.
B. Mark the drainage output on the collection chamber hourly.
C. Clamp the chest tube every 2 hours to assess the amount of drainage.
D. Add water to the waterseal chamber as it evaporates.
E. Strip the chest tube vigorously to dislodge blood clots.
39. The nurse is reviewing a medical record of a client who has a prescription for intermittent heat
therapy for a foot injury. Which of the following findings should the nurse identify as a
contraindication to heat therapy?
A. Osteoarthritis
B. Peripheral neuropathy
C. Abdominal aortic aneurysm
D. Phlebitis
40. A charge nurse is recommending postpartum clientsfor discharge following a local disaster. Which of
the following client’s should the nurse recommend for discharge first?
A. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
B. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
C. A client who delivered precipitously and has a second-degree perineal laceration
D. A client who hasreceived 2 units of RBCs 6 hr ago for a postpartum hemorrhage
41. A nurse is providing teaching about crutch safety to a client. Which of the following client actions
indicates an understanding of the teaching?
A. The client flexes her elbows 10 degrees when supporting weight by using the handgrips. ATI
page 222 Fundy. IT HAS TO BE 30 DEGREE
B. The client placesthe crutches 30 cm (12 in) to the front and side of each foot while standing
C. The client leans on both crutchesto support body weight.
D. The client keeps her axillae free of pressure.
42. A nurse is preparing the body of a client who has died for the family to view. Which of the following
actions should the nurse take?
A. Place a pillow under the client’s head.
B. Remove the client’s dentures.
C. Remove the client’sidentification tags.
D. Place the client’s arms across their chest.
43. A nurse isreviewing annual education requirementsfor fire safety. Identify the sequence that the
nurse should use when operating a fire extinguisher.
1. Unlock the handle by pulling on the pin.
2. Point the hose at the base of the fire.
3. Squeeze the handlestogether.
4. Sweep the extinguisher from side to side.
44. 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. Ensure that the client has a living will on file prior to treatment.
B. Place copies of incident reports in the clients’ medical records.
C. Obtain personal professional liability insurance coverage.
D. Overestimate the clients’ acuity to preventshortstaffing.
45. A nurse is caring for a client who speaks a language different than the nurse. Which of the following
actions should the nurse make?
A. Review the facility policy about the use of an interpreter.
B. Direct attention toward the interpreter when speaking to the client.
C. Request a family member or friend to interpret information to the client.
D. Request an interpreter of a differentsex from the client.
46. A nurse in the emergency department is caring for a client following a motor-vehicle crash. Which of
the following findings should the nurse identify as a manifestation of hypovolemic shock?
A. Decreased respiratory rate
B. Change in level of consciousness
C. Increased urine output
D. Hyperactive deep-tendon reflexes
47. A nurse is caring for a client following application of a cast. Which of the following actionsshould the
nurse take first?
A. Position the casted extremity on a pillow.
B. Place an ice pack over the cast.
C. Teach the client to keep the cast clean and dry.
D. Palpate the pulse distal to the cast.
48. A nurse is performing a gait assessment on a client to evaluate the client’s ability to perform ADLs.
Which of the following findings indicates a standard gait?
A. The client looks at the floor when walking.
B. The client’s shoulders are rounded slightly forward.
C. The client’s heelstouch the ground before theirtoes.
D. The client’s dominant foot bears more weight.
49. A nurse on a mental health unit is caring for a client who hassuicidal ideation. Which of the
following actions should the nurse take?
A. Place the client in a group therapy session.
B. Avoid discussing suicidal thoughts with the client.
C. Give the client a radio to listen to in his room.
D. Establish a no-suicide contract with the client.
50. A nurse is providing teaching about nutrition therapy to a client who is experiencing anorexia due to
chemotherapy treatment. Which of the following statements should the nurse make?
A. “Snack frequently on fresh fruit.”
B. “Add waterto soupsto increase volume.”
C. “Avoidadding butterto foods.”
D. “Add grated cheese to vegetable dishes.”
51. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about
administering NPH and regular insulin together in one injection. Which of the following instructions
should the nurse include?
A. Inject into the vastuslateralis.
B. Draw up the regular insulin prior to NPH.
C. Use a 15-degree angle for the injection.
D. Roll the syringe gently to ensure mixture of the insulins.
52. A nurse is caring for a client who has a calcium level of 8 mg/dL. Which of the following actions
should the nurse take?
A. Request a prescription for magnesium citrate.
B. Request a prescription for furosemide.
C. Place the client on a low-calcium diet.
D. Place the client on seizure precautions.
53. A nurse is caring for a client who hasschizophrenia and is experiencing delusions. Which of the
following actions should the nurse take?
A. Encourage the client to rest quietly in bed twice per day.
B. Direct long conversations about the delusionstoward reality-based topics.
C. Allow the client unlimited time to discussthe delusions when they occur.
D. Avoid assessing the client’s delusions.
54. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the
following disorders is a contraindication for oral contraceptive use?
A. Asthma
B. Fibromyalgia
C. Hypertension
D. Fibrocystic breast condition
55. A nurse in the emergency department istriaging victims of a house fire. Which of the following
clients should the nurse prioritize as emergent?
A. Client who has a compound fracture of the femur
B. Client who has hypertension and reports chest pain
C. Client who hassevere abdominal pain
D. Client who has a deep laceration on both thighs
56. A nurse is planning care for a group of clients. Which ofthe following methods should the nurse use
to manage time effectively?
A. Gathersupplies prior to completing a dressing change.
B. Complete partial assessments on all clients before planning the day.
C. Prioritize activities based on the nurse’s needs.
D. Use break time to perform documentation.
57. A nurse on a mental health unit is planning room assignments for four clients. Which of the following
clients should the nurse assign to room near the nurse’s station?
A. A client who has a somatic symptom disorder and reports chronic pain.
B. A client who has an anxiety disorder and is experiencing moderate anxiety.
C. A client who has bipolar disorder and impaired social interactions.
D. A client who has a depressive disorder and reports feeling hopeless.
58. A nurse is assessing coping strategies of a client whose partner has alcohol use disorder. Which of
the following findings indicates that the client is coping effectively?
A. The client utilizesstrategiesto enhance codependent behaviors.
B. The client attends regular counseling sessions.
C. The client exhibitssympathy to the partner.
D. The client ignoresthe partner when they are using alcohol.
59. A nurse is caring for a client who has Graves’ disease and is experiencing a thyroid storm. Which of
the following actions is the nurse’s priority?
A. Obtain the client’s blood glucose.
B. Administer 0.9% sodium chloride IV.
C. Provide a cooling blanket.
D. Monitorthe client’s cardiac rhythm. This has more priority
60. A nurse is providing preoperative teaching to a client about promoting circulation during the
postoperative period. Which of the following instructions should the nurse include?
A. “Remain on bed rest for 24 hoursfollowing the procedure.”
B. “Use an incentive spirometer every 4 hours.”
C. “Participate in range-of-motion exercises.”
D. “Place a pillow under your knees while in bed.”
61. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following
actionsshould the nurse when pouring the sterile solution?
A. Hold the bottle in the center of the sterile field when pouring the solution.
B. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
C. Place the sterile gauze over areas ofspilled solution within the sterile field.
D. Remove the cap and place it sterile-side up on a clean surface.
62. A nurse is conducting a home visit for a family who has two young children. The nurse notes several
welts across the back of the legs of one of the children. Which of the following actions should the
nurse take first?
A. Contact child protective services.
B. Referthe parentsto a self-help group.
C. Instruct the parents about methods of discipline.
D. Document clinical findings.
63. A nurse is teaching a client who is to undergo placement of a non-tunneled percutaneous central
venous access device. Which of the following statements should the nurse include in the teaching?
A. “The provider will wear a mask while performing the procedure.”
B. “You should not eat or drink for 4 hours prior to the procedure.”
C. “Your head will be elevated as high as possible while the catheteris inserted.”
D. “The provider will give you pain medication before inserting the catheter.”
64. A nurse in a clinic isreviewing the health history of a client during her first prenatal visit. Which of
the following findings indicates a risk for gestational diabetes mellitus?
A. 1-hr glucose tolerance test if 128 mg/dL
B. Previousmiscarriage
C. Delivery of a low birth-weight infant
D. BMI of 31
65. A nurse is caring for a client who is incontinent and has a stage II pressure injury on their coccyx.
Which of the following interventions should the nurse implement?
A. Apply lotion to the skin every 4 hr.
B. Reposition the client every 3 hr.
C. Position the client laterally at 30 degrees.
D. Have two facility personnel help to slide the client up in bed.
66. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do
not speak the same language as the clinic staff. Which of the following instructions should the nurse
include?
A. Offer clientstranslation servicesfor a nominal fee.
B. Use clients’ children to provide interpretation.
C. Evaluate clients’ understanding at regularintervals.
D. Direct questionsto amedical interpreter.
67. A nurse is caring for an infant who isin contact isolation and received a blood transfusion. Which of
the following actions is appropriate for the nurse to provide cost-effective care?
A. Leave the unused infusion pump in the room until discharge.
B. Bring in formula as needed.
C. Return unopened equipment to the supply center.
D. Stock the room with a 2-day supply of disposable diapers.
68. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the following
prescriptionsshould the nurse expect the provider to prescribe?
A. Interferon beta-1a
B. Enoxaparin
C. Atorvastatin
D. Amoxicillin
69. A nurse isspeaking with the partner of a client who isin the early stage of Alzheimer’s disease. The
partner tellsthe nurse thatshe is able to manage the client’s physical care, but she doesn’t want to
leave him home alone while she travelsfor work. Which of the following referralsshould the nurse
make?
A. Respite care
B. Restorative care
C. Hospice
D. Rehabilitation facility
70. A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting.
Which of the following manifestations should the nurse expect?
A. Orthostatic hypotension
B. Decreased respirations
C. Polyuria
D. Bradycardia
71. A nurse is caring for a client who is at 14 weeks of gestation and reportsfeelings of ambivalence
about being pregnant. Which of the following responses should the nurse make?
A. “When did you start having these feelings?”
B. “Have you discussed these feelings with your partner?”
C. “You should discuss yourfeelings about being pregnant with your provider.”
D. “Describe your feelings to me about being pregnant.”
72. A nurse manager is planning to promote client advocacy among staff on a medical unit. Which of the
following actions should the nurse plan to take?
A. Instruct unit staff to share personal experiences to help clients make decisions.
B. Encourage staff to implement the principle of paternalism when a client is having difficulty
making a choice.
C. Develop a system for staff membersto reportsafety concernsin the client care environment.
D. Tellstaffto explain proceduresto clients before obtaining informed consent.
73. A nurse received a telephone call from a parent reporting that theirschool-age child has a
nosebleed and that they cannot stop the bleeding. Which of the following instructions
should the nurse provide for the parent?
A. “Place a warm, wet washcloth over your child’sforehead and the bridge of their nose.”
B. “Tell your child to blow their nose gently, and then sit down and tilt their head
backward.”
C. “Use yourthumb and forefinger to apply pressure to the sides of your child’s nose.”
D. “Have your child lie down and turn their head to the side for 10 minutes.”
74. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment
prescribed by a wound care consultant. For which of the following findings should the nurse
contact the consultant to revise the plan of care?
A. Hgb 15 g/dL.
B. Appearance of pink tissue under eschar.
C. Albumin level 4.0 g/dL
D. Weight loss of 5% in 10 days.
75. A nurse is performing an abdominal assessment as part of a client’s comprehensive physical
examination. Which of the following isthe finalstep the nurse should perform?
A. Inspection
B. Palpation
C. Auscultation
D. Percussion
76. A nurse is caring for a client who has an NG tube in place for gastric decompression and
notesthat the tube is not draining. Which of the following stepsshould the nurse take first?
A. Check the functioning of the suction equipment.
B. Reposition the NG tube.
C. Instill an irrigation solution slowly.
D. Inject 20 mL of air and aspirate in the NG tube.
77. A nurse is caring for a client who has major depressive disorder. Which of the following
findingsshould indicate to the nurse that the client’s condition is improving?
A. The client avoids eye contact with others.
B. The client exhibits a flat affect.
C. The client participates in self-care.
D. The client experiences self-doubt when making decisions.
78. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes
that the client coughs after each bite. After asking the AP to stop feeding the client, which of
the following actions should the nurse take next?
A. Provide the client with an instructional handout about swallowing exercises.
B. Ask a speech therapist to evaluate the client’s ability to swallow.
C. Discussthe manifestations of impaired swallowing with the AP.
D. Listen to the client’slung sounds.
79. A nurse in an acute mental health facility is prioritizing care for multiple clients. Which of the
following clients should the nurse see first?
A. A client who has obsessive-compulsive disorder and is upset about change in daily
routine
B. A client who has depressive disorder and requires assistance with ADLs
C. A client who has narcissistic personality disorder and is mocking others during group
therapy
D. A client who istaking clozapine to treat schizophrenia and reports a sore throat
80. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive
personnel (AP). Which of the following statementsshould the nurse include in the teaching?
A. “The RN evaluates client needs to determine tasks to delegate.”
B. “An AP can perform tasks outside of hisrange of function if he has been trained.”
C. “An experienced AP can delegate tasksto another AP.”
D. “The RN islegally responsible forthe actions of the AP.”
81. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago.
Which of the following findings should the nurse expect?
A. Memory loss
B. Hypotension
C. Elevated temperature
D. Slurred speech
82. A nurse administered 400mg of ibuprofen to a client 2 hr ago to treat pain following a
biopsy. The client is crying and states, “It really still hurts a lot.” Which of the following
actions should the nurse take?
A. Administer an additional dose of ibuprofen to the client.
B. Request a prescription for an opioid pain medication forthe client.
C. Reportthis client finding to the provider.
D. Ask the client to rate their pain on a scale of 0 to 10.
83. A nurse is planning care for an older adult client who has dementia. Which of the following
interventions should the nurse include in the plan of care? (SATA)
A. Allow the client to choose among a variety of activities each day.
B. Refute the client’s delusions using logic.
C. Establish eye contact when communicating with the client.
D. Reinforce orientation to time, place, and person.
E. Give the client one simple direction at a time.
84. A nurse is providing nutritional teaching to a client who is experiencing severe nausea.
Which of the following responses by the client indicates an understanding of the teaching?
A. “Ishould increase my intake of liquids with meals.”
B. “Ishould focus on eating complex carbohydrates.”
C. “Ishould lie down after my meals.”
D. “Ishould sip on clear carbonated beveragesthat have gone flat.”
85. A nurse is providing teaching about disulfiram to a client who has alcohol use disorder.
Which of the following statements should the nurse make?
A. “Wait at least 12 hr after your last drink to take this medication.”
B. “Alcoholshould not be consumed for 3 daysfollowing yourlast dose.”
C. “This medication will decrease yourrisk for delirium during your withdrawal from
alcohol.”
D. “This medication will prevent seizures during your withdrawal from alcohol.”
86. A nurse is assessing a client following an ischemic stroke. Which of the following findingsis
the priority for the nurse to report to the provider?
A. The client reports a metallic taste in his mouth.
B. The client has poor-fitting dentures.
C. The client reports a decreased appetite.
D. The client coughs after swallowing.
87. A nurse is creating a plan of care for a client who has paranoid personality disorder and
refuses to take their medication. Which of the following interventions should the nurse
include in the plan?
A. Limit the client’s opportunitiesto socialize with others.
B. Mix the medication with the client’sfood items.
C. Rotate staff members caring forthe client.
D. Speak in a neutral tone when addressing the client.
88. A nurse is assessing a client immediately following a cardiac catheterization. The nurse
should notify the provider for which of the following findings?
A. Report of discomfort at the insertion site.
B. Hematoma over the insertion site.
C.
D. Bounding pulsesin the affected extremity.
E. Heart rate 90/min
89. A home care nurse is making a follow-up visit with a client who has COPD and is using a
compressed oxygen system in his home. Which of the following actions should the nurse
take?
A. Have the clientstore smaller tanks under his bed.
B. Place the oxygen tank away from curtains or drapes.
C. Ensure that the client checksthe gauge weekly.
D. Store the oxygen tank wrench in a locked cabinet.
90. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which
of the following statements by the client indicates an understanding of the teaching.
A. “I don’t need to use a walker when walking around my house.”
B. “I willstart my leg exercises 3 days after returning home.”
C. “I won’t cross my legs when sitting in a chair.”
D. “I will bend at the hips when tying my shoes.”
91. A nurse isteaching a client about the oral administration of chlorpromazine. Which of the
following information should the nurse include?
A. Move slowly when standing from a sitting position.
B. Expect loose stools as an adverse effect.
C. Anticipate an increase in saliva production.
D. Monitorfor an increase in the occurrence of hiccups.
92. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The
client reports that she is experiencing difficulty breathing. Which of the following actions
should the nurse take first?
A. Assessthe fetal heart rate.
B. Discontinue the infusion.
C. Administer calcium gluconate.
D. Obtain the client’s magnesium level.
93. A nurse isreviewing the laboratory results of a client who istaking cyclosporine following a
kidney transplant. Which of the following findingsshould the nurse report to the provider?
A. BUN mg/dL
B. Urine specific gravity 1.023
C. Serum creatinine 1.6 mg/dL
D. Urine pH 6.2
94. A nurse is caring for a client who is on fall precautions. Which of the following actionsshould
the nurse take?
A. Allow the clientto walk unassisted near the nursing station.
B. Establish an elimination schedule for the client.
C. Silence the bed alarm when visitors are at the client’s bedside.
D. Raise all four bed rails on the client’s bed.
95. A nurse on a medical-surgical unit is caring for a client who states that she plansto leave the
facility against medical advice. For which of the following actions by the nurse should the
charge nurse intervene?
A. Askssecurity to detain the client until the provider is notified.
B. Asksthe client what her plans are for follow-up care.
C. Showsthe client her abnormal laboratory results.
D. Asksthe client to sign a form releasing the hospital from legalresponsibility.
96. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which of the following nursing interventions should the nurse include in the plan of
care for this client?
A. Flush IV tubing with hypotonic solution.
B. Encourage oral hydration of 1,800mL daily
C. Perform neurologic checks.
D. Weigh the client weekly.
97. A nurse is using an IV pump for a newly admitted client. Which of the following actions
should the nurse take?
A. Check the cords of the IV pump for fraying.
B. Grasp the IV pump cord when unplugging it from the electrical outlet.
C. Remove the safety inspection sticker before plugging in the IV pump. [Show Less]