A young adult who is hit with a baseball bat on the temporal area of the left skull is
conscious when admitted to the ED and is transferred to the Neurolo... [Show More] gical Unit to be monitored
for signs of closed head injury. Which assessment finding is indicative of a developing epidural
Altered consciousness within the first 24 hours after injury.
A female client with breast cancer who completed her first chemotherapy treatment today
at an out-patient center is preparing for discharge. Which behavior indicates that the client
understands her care needs
Rented movies and borrowed books to use while passing time at home
Which instruction should the nurse provide a pregnant client who is complaining of
Eat small meal throughout the day to avoid a full stomach.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary
gland tumor. Which potential complication should the nurse monitor closely?
Elevated blood pressure
Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes
insipidus, which causes massive polyuria and serum electrolyte imbalances, including
hypokalemia, which can lead to lethal arrhythmias.
A female client reports she has not had a bowel movement for 3 days, but now is
defecating frequent small amount of liquid stool. Which action should the nurse implement?
Digitally check the client for a fecal impaction
After changing to a new brand of laundry detergent, an adult male reports that he has a
fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?
The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that
the symptom of acute episode of asthma are due to which physiological response?
Inflammation of the mucous membrane & bronchospasm
A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my
body when I die?" How should the nurse respond?
"The heart will stop beating & you will stop breathing."
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:
Increased pulse rate
Increased respiratory rate.
Peripheral pallor of the skin
The nurse is preparing to administer an oral antibiotic to a client with unilateral
weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing
assessment that should be done before administering this medication?
Determine which side of the body is weak.
The nurse who is working on a surgical unit receives change of shift report on a group of
clients for the upcoming shift. A client with which condition requires the most immediate
attention by the nurse?
Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain.
Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container
Abdominal-perineal resection 2 days ago with no drainage on dressing who has
fever and chills.
Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and
needs to be immediately assessed for other signs and symptoms for sepsis.
The nurse is caring for a client who had gastric bypass surgery yesterday. Which
intervention is most important for the nurse to implement during the first 24 postoperative
Measure hourly urinary output.
Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak,
often resulting in death.
When preparing to discharge a male client who has been hospitalized for an adrenal
crisis, the client expresses concern about having another crisis. He tells the nurse that he wants
to stay in the hospital a few more days. Which intervention should the nurse implement?
Schedule an appointment for an out-patient psychosocial assessment.
An adult female client tells the nurse that though she is afraid her abusive boyfriend
might one day kill her, she keeps hoping that he will change. What action should the nurse take
Explore client’s readiness to discuss the situation.
In caring for a client with Cushing syndrome, which serum laboratory value is most
important for the nurse to monitor?
Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and
recurrent chlamydia. What information is most important for the nurse to provide to this client?
Use two forms of contraception while taking this drug.
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports
sleeping only three hours during the past 48h. Based on these finding, it is most important for
the nurse to review the laboratory value for which medication?
Rationale: divalproex is the first line of treatment for bipolar disorder BPD because it has
a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and
preventing recurrent episodes of mania and depression. The serum value of divalproex should
be determined since the client is exhibiting symptoms of mania, which may indicate noncompliance with the medication regimen.
A male client who is admitted to the mental health unit for treatment of bipolar disorder
has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most
important for the nurse to report to the healthcare provider?
Serum lithium level of 1.6 mEq/L or mmol/l (SI)
Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI).
Slurred speech and ataxia are sign of lithium toxicity.
A client was admitted to the cardiac observation unit 2 hours ago complaining of chest
pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular
ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an
elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in
the anterior leads. What intervention should the nurse perform?
Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal
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 client is being discharged with a prescription for warfarin (Coumadin). What
instruction should the nurse provide this client regarding diet?
Eat approximated the same amount of leafy green vegetables daily so the amount of
vitamin K consumed is consistent.
A client who had a small bowel resection acquired methicillin resistant staphylococcus
aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of
diarrhea and dehydration. It is most important for the nurse to implement which intervention.
Maintain contact transmission precaution
1. A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours
for pain. One dose of morphine was administered when the client was admitted to the post
anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her
current respiratory rate is 8 breaths/minute. What action should the nurse take?
Administer Naxolone IV
Which intervention is most important for the nurse to include in the plan of care for an
older woman with osteoporosis?
Place the client on fall precautions
Based on the information provided in this client’s medical record during labor, which
should the nurse implement? (Click on each chart tab for additional information. Please be sure
to scroll to the bottom right corner of each tab to view all information contained in the client’s
Continue to monitor the progress of labor.
An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what
order should the unit manager implement this intervention to address the UAPs behavior? (Place
the action in order from first on top to last on bottom.)
1. Note date and time of the behavior.
2. Discuss the issue privately with the UAP.
3. Plan for scheduled break times.
4. Evaluate the UAP for signs of improvement.
1. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and
is receiving an IV of lactated ringer’s at 100 ml/H. which finding is most important for the nurse
to report to the healthcare provider?
Serum potassium level of 3.1 mEq/L or mmol/L (SI)
Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter
Which type of Leukocyte is involved with allergic responses and the destruction of
Rationale: Eosinophils are involved in allergic responses and destruction of parasitic
The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for
a client with a postoperative wound infection. Which foods should the nurse encourage this
client to eat?
Yogurt and/or buttermilk.
Several months after a foot injury, and adult woman is diagnosed with neuropathic pain.
The client describes the pain as severe and burning and is unable to put weight on her foot. She
asks the nurse when the pain will “finally go away.” How should the nurse respond?
Assist the client in developing a goal of managing the pain
One day following an open reduction and internal fixation of a compound fracture of the
leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the
client’s left pedal pulses are diminished. Based on these finding, what is the client’s greatest
Neurovascular and circulation compromise related to compartment syndrome.
The nurse is completing a head to be assessment for a client admitted for observation
after falling out of a tree. Which finding warrants immediate intervention by the nurse?
Clear fluid leaking from the nose.
A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath
(Uhthoff’s sign). Which pathophysiological mechanism supports this response?
While assessing a radial artery catheter, the client complains of numbness and pain distal
to the insertion site. What interventions should the nurse implement?
Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding
accident. To differentiate the vascular source of the intracranial bleeding, which finding should
the nurse monitor?
Rapid onset of decreased level of consciousness.
The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to
cardiopulmonary resuscitation (CPR) should the nurse implement?
Position a firm wedge to support pelvis and thorax at 30 degree tilt.
When preparing a client for discharge from the hospital following a cystectomy and a
urinary diversion to treat bladder cancer, which instruction is most important for the nurse to
include in the client’s discharge teaching plan?
Report any signs of cloudy urine output.
For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a
bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take
Tented skin turgor.
After repositioning an immobile client, the nurse observes an area of hyperemia. To
assess for blanching, what action should the nurse take?
Apply light pressure over the area.
The nurse enters a client’s room and observes the client’s wrist restraint secured as seen
in the picture. What action should the nurse take?
Reposition the restraint tie onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed
and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment
finding warrants immediate intervention by the nurse?
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax,
which required immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the
pathophysiological events in orders of occurrence. (Place the first event on top and the last on
1. Arterial endothelium injury causes inflammation
2. Macrophages consume low density lipoprotein (LDL), creating foam cells
3. Foam cells release growth factors for smooth muscle cells
4. Smooth muscle grows over fatty streaks creating fibrous plaques
5. Vessel narrowing results in ischemia
1. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine
output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse’s
decision to report this finding to the healthcare provider?
Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective?
Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse
asks the client to perform a series of movements that require use of the facial muscles. What
symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke?
Inability to close the affected eye, raise brow, or smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the
client’s return demonstration, which action indicated that the client understood the teaching?
Keeps the irrigating container less than 18 inches above the stoma
The nurse should teach the client to observe which precaution while taking dronedarone?
Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client’s risk for developing increased intracranial pressure (ICP)
in the plan of care. Which signs indicate to the nurse that ICP has increased?
Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of increased ICP. Other options do not necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a single lumen
central venous catheter (CVC). Based on the CVC care bundle, which action should be
completed daily to reduce the risk for infection?
Confirm the necessity for continued use of the CVC.
During an annual physical examination, an older woman’s fasting blood sugar (FBS) is
determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a
follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?
Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A new mother tells the nurse that she is unsure if she will be able to transition into
parenthood. What action should the nurse take?
Determine if she can ask for support from family, friend, or the baby’s father.
A client who was admitted yesterday with severe dehydration is complaining of pain a 24
gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the
nurse implement first?
Stop the normal saline infusion.
An elderly female is admitted because of a change in her level of sensorium. During the
evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin
traction is applied to the left leg while waiting for surgery. Which intervention is most important
for the nurse to include in this client’s plan care?
Ensure proper alignment of the leg in traction.
An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the
Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site
contains bright red tissue. What action should the nurse take in response to this finding?
Document the ongoing wound healing.
At the end of a preoperative teaching session on pain management techniques, a client
starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing
diagnosis for this client?
The nurse note a visible prolapse of the umbilical cord after a client experiences
spontaneous rupture of the membranes during labor. What intervention should the nurse
Elevate the presenting part off the cord.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%.
The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for
rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should
the nurse give the healthcare provider?
Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the
nurse include in this client’s teaching plan? (Select all that apply.)
Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
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
Written at a twelfth grade reading level
Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and
shorter attention span. Materials for this age group should include at least of terms, such as a
medical terminology that incline may not know and use common words that expresses
information clearly and simply. Simple, attractive pictures help hold the learner’s attention. The
reading level of material should be at the 4th to 5th grade level. Materials should be printed
using large font (18-point or higher), not the standard 12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client with no
history of cardiovascular disease. Where should the nurse listen when assessing the client’s
point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the client has
become increasingly disoriented. The night shift nurse reports that he attempted to remove the
sandbag from his femoral artery multiple times during the night. What actions should the nurse
take? (Select all that apply.)
Notify the healthcare provider of the client’s change in mental status.
Include q2 hour’s reorientation in the client’s plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to take
the client’s health history, he does not respond to questions in a clear manner. What action
should the nurse implement first?
Assess the surroundings for noise and distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has
voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate
that client will need?
Large amounts of fluid and electrolyte replacement.
Which intervention should the nurse include in the plan of care for a child with tetanus?
Minimize the amount of stimuli in the room
Suicide precautions are initiated for a child admitted to the mental health unit following
an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in
the client’s room. Which intervention is most important for the nurse to implement?
Remove cigarettes for the client’s room
A family member of a frail elderly adult asks the nurse about eligibility requirements for
hospice care. What information should the nurse provide? (Select all that apply.)
A client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.
A client with atrial fibrillation receives a new prescription for dabigatran. What
instruction should the nurse include in this client’s teaching plan?
Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
A nurse with 10 years experience working in the emergency room is reassigned to the
perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
A mother with an infected episiotomy
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN),
and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the
Supervise a newly hired graduate nurse during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the
client stares into the distance and appears to be concentrating on something other than the lesson
the nurse is presenting. What action should the nurse take?
Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency room
complaining of chest tightness and shortness of breath. History includes end stage chronic
obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary
assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should
the nurse implement? (Select all that apply.)
Administer PRN nebulizer treatment.
Obtain 12 lead electrocardiogram.
Monitor continuous oxygen saturation.
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant
is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action
should the nurse take?
Administer a prescribed analgesia for pain. [Show Less]