Which location should the nurse choose as the best for beginning a screening program for
hypothyroidism?
A business and professional women's
... [Show More] group.
An African-American senior citizens center
A daycare center in a Hispanic neighborhood
An after-school center for Native-American teens
46. A female client has been taking a high dose of prednisone, a corticosteroid, for several
months. After stopping the medication abruptly, the client reports feeling “very tired”.
Which nursing intervention is most important for the nurse to implement?
Measure vital signs
Auscultate breath sounds
Palpate the abdomen
Observe the skin for bruising
47. A male client reports the onset of numbness and tingling in his fingers and around his
mouth. Which lab is important for the nurse to review before contacting the health care
provider?
capillary glucose
urine specific gravity
Serum calcium
white blood cell count
48. What explanation is best for the nurse to provide a client who asks the purpose of using
the log-rolling technique for turning?
working together can decrease the risk for back injury
The technique is intended to maintain straight spinal alignment.
Using two or three people increases client safety.
turning instead of pulling reduces the likelihood of skin damage
49. A client receiving chemotherapy has severe neutropenia. Which snack is best for the
nurse to recommend to the client?
Baked apples topped with dried raisins
50. Which action should the school nurse take first when conducting a screening for
scoliosis?
Inspect for symmetrical shoulder height.
51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to
the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What
action should the charge nurse implement?
Assign a practical nurse (LPN) to determine if an apical radial deficit is present
52. After a sudden loss of consciousness, a female client is taken to the ED and initial
assessment indicate that her blood glucose level is critically low. Once her glucose level
is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is
being treated at an outpatient clinic. Which intervention is more important to include in
this client’s discharge plan?
Encourage a low-carbohydrate and high-protein diet
53. A client with a peripherally inserted central catheter (PICC) line has a fever. What client
assessment is most important for the nurse to perform?
Observe the antecubital fossa for inflammation.
54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate
the medication’s effectiveness, which laboratory values should the nurse monitor? Select
all that apply
White blood cell (WBC) count
Sputum culture and sensitivity
55. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection
control measures should the nurse implement?
Negative pressure environment
contact precautions
droplet precautions
protective environment
56. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In
what position should the nurse place the child?
Sitting up and leaning forward
57. 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 Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
Altered consciousness within the first 24 hours after injury.
58. 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
59. Which instruction should the nurse provide a pregnant client who is complaining of
heartburn?
Eat small meal throughout the day to avoid a full stomach.
60. 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?
Hypokalemia
Ketonuria.
Peripheral edema
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.
61. 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
62. 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?
Bilateral Wheezing.
63. 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
64. 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."
65. 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:
Restlessness
Clenched Fist
Increased pulse rate
Increased respiratory rate.
Increased temperature
Peripheral pallor of the skin
66. 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.
67. 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.
68. 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 hours?
Measure hourly urinary output.
Rationale: a serious early complications of gastric bypass surgery is an
anastomoses leak, often resulting in death.
69. 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.
70. 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 first?
Explore client’s readiness to discuss the situation.
71. In caring for a client with Cushing syndrome, which serum laboratory value is most
important for the nurse to monitor?
Lactate
Glucose
Hemoglobin
Creatinine
72. 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.
73. 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?
Divalproex.
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 non-compliance with the medication
regimen.
74. 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.
75. 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 cannula.
76. The nurse is developing a teaching program for the community. What population
characteristic is most influential when choosing strategies for implementing a teaching
plan?
Literacy level
77. 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.
78. 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
79. 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
80. 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
81. 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 medical record.)
Continue to monitor the progress of labor.
82. 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.
83. 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
(mEq/L).
84. Which type of Leukocyte is involved with allergic responses and the destruction of
parasitic worms?
Neutrophils
Lymphocytes
Eosinophils
Monocytes
Rationale: Eosinophils are involved in allergic responses and destruction of
parasitic worms.
85. 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.
86. 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
87. 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 risk?
Neurovascular and circulation compromise related to compartment syndrome.
88. 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.
89. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath
(Uhthoff’s sign). Which pathophysiological mechanism supports this response?
Temporary vasodilation
90. 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 [Show Less]