1. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left
... [Show More] midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings?
b. Murmur at the mitral area
2. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching?
c. I will remove bananas from my diet
3. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?
c. Renal insufficiency
4. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
a. Contractions -
5. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first?
d. I will determine which muscles to contract by stopping and starting my stream of urine
6. A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching?
I will determine which muscles to contract by stopping and starting my stream of urine
7. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching?
b. I should urinate before the test
8. 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?
c. Elevated temperature
9. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client?
b. Scratchy, high pitched sound upon chest auscultation
10. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?
b. Consume food high in bran fiber
11. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse?
b. Privately interview the client about her condition.
12. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?
a. Maintain NPO status for client(ABC)
13. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
b. “I will need to increase my insulin doses later in my pregnancy”
14. A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first?
a. Test the client for Trousseau’s sign
15. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching?
c. “I should change the stoma pouch every day”
16. A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity?
a. Hyporeflexia
17.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)
Answer is 1.7 mL per dose Rationale:
100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736
18.A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
a. “Your desire to be an organ donor must be documented in writing”
19.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
a. Administer enalapril 2.5 mg PO twice daily
20.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
b. Clamp the catheter distal to the injection port
21. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations?
A. Orthostatic Hypertension
22. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
B. The client exhibits impulsive behavior.
23. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
B. Protruding Hemorrhoids
24. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first?
A. Inform the provider of the time of the last dose of pain medication.
25. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
B. The estimated blood loss was 250 milliliters.
26. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
D. “Have your child drink a small glass of water after swallowing the medication.”
27. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?
A. Left ventricular failure
28. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
D. A client who is receiving heparin for deep vein thrombosis.
29. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?
A. Fasting blood glucose 108 mg/dl (WNL)
30. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? Paul for 158 would u pick D?
D. Use clothing with buttons and zippers.
31. The clinic nurse is obtaining cardiovascular data on a client. The LPN/LVN prepares to check the client's apical pulse and places the stethoscope in which position?
4. At the midclavicular line at the fifth left intercostal space
32) The LPN/LVN is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen
3. Deficient oxygenation to heart cells results in angina pectoris pain.
33) The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)?
3. Respirations and blood pressure
34) A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?
4. "I need to adhere to my dietary restrictions."
35) The LPN/LVN is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu.
Which beverage does the nurse instruct the client to select from the menu?
4. Lemonade
36) The LPN/LVN is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question?
2. "Where is the pain located?"
37) The LPN/LVN has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?
3. "I should routinely use polyunsaturated oils in my diet."
38) The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?
1. Tall, peaked T waves
39) The LPN/LVN is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?
2. ST-segment depression
40) While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic?
3. "So you're saying that you want to talk to your health care provider?"
41) The LPN/LVN reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
2. "I should avoid sitting in one position for long periods of time."
42) A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The LPN/LVN interprets that the client is experiencing which type of angina?
1. Stable
43) The LPN/LVN is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching?
2. "It is best to exercise once a week for an hour."
44) The LPN/LVN is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client?
4. Prinzmetal's angina is generally treated with calcium channel blocking agents.
45) The LPN/LVN working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse?
3. The pain has not been unrelieved by rest and nitroglycerin tablets.
46) The LPN/LVN is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking?
4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."
47) A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect?
3. Weight gain of 2 to 3 pounds in a few days
48) A client has experienced an episode of pulmonary edema. The LPN/
LVN determines that the client's respiratory status is improving if which breath sounds are noted?
3. Crackles in the lung bases
49) A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted?
2. Relief of apprehension
50) The LPN/LVN is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement?
1. "I will take this medication every day."
51) The LPN/LVN determines that a client with coronary artery disease
(CAD) needs further teaching about disease management if the client makes which statement?
2. "I will avoid walking for exercise.
52) The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?
3. The client complains of leg edema, and skin breakdown has started.
53) A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure?
4. "The best thing about this is that I can use it anywhere, anytime."
54) A client, who is 36 hours post-myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made?
3. The pre activity pulse rate is 86 beats per minute; the post activity pulse rate is 94 beats per minute.
55) The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner choice from the daily menu?
2. Baked pollock, mashed potatoes, and carrot-raisin salad
56) A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms?
1. Chest pain
57) The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease?
3. Numbness and tingling in the legs
58) The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe?
2. Two pounds per week [Show Less]