TEST BAK NCLEX QUESTIONS 1-15
Ref # 4366 The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft
... [Show More] procedure. Which of the following assessments requires immediate notification of the health care provider? Left foot is cool to the touch Absent left pedal pulse using Doppler analysis Inability to palpate the left pedal pulse Acute pain in the left lower leg
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider.
Ref # 1028 There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order.
Ref # 1440 Which individual is at greatest risk for the development of hypertension? 45 year-old African-American attorney The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising.
Ref # 2446 A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Ask the client to stay on the line, get the address, and send an ambulance to the homeThe woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to,
during, or after delivery; this may occur up to 10 days after delivery.
Ref # 2065
A client expresses anger when a call light is not answered within five minutes.
The client demanded a blanket. How should the nurse respond?
"I see this is frustrating for you. I have a few minutes so let's talk."
This is the best response because it gives credence to the client's feelings and then concerns. To say
"let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or
validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it
could have waited a few minutes is rude and non-accepting of the client's verbalized needs.
Ref # 2134
The client is admitted to an ambulatory surgery center and undergoes a right
inguinal orchiectomy. Which option is the priority before the client can be
discharged to home
Post-operative pain is managed
An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer
(testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with
an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men
will be able to eat regularly when they get home; they should at least tolerate liquids before discharge.
It's important that the client is able to get up and walk with assistance, but this is not the priority.
Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate
priority.
Ref # 1524
A nurse is teaching a group of adults about modifiable cardiac risk factors.
Which of the following should the nurse focus on first?
Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in
reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be
addressed at some point in time.
Ref # 1721
The clinic nurse is assisting with medical billing. The nurse uses the DRG
(Diagnosis Related Group) manual for which purpose?
Determine reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other
insurance companies often use it as a standard for determining payment. KEYWORDS DRG
diagnosis related group
reimbursementRef # 1328
A nurse is planning care for a 2 year-old hospitalized child. Which issue will
produce the most stress at this age? Separation anxiety While a toddler will experience all of
the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years.
Ref # 2319
The nurse is reviewing the laboratory results for several clients. Which of the
laboratory result indicates a client with partly compensated metabolic acidosis?
PaCO2 30 mm Hg
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea,
dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a
low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying
to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory
decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both
males and females. The chloride and sodium results are also WNL.
Ref # 2391
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA)
has died. Which type of precautions is appropriate to use when performing
postmortem care? Contact precautionsThe resistant bacteria remain alive for up to three days
after the client dies. Therefore, contact precautions must still be used. The body should also be labeled
as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves
are required.
Ref # 1436
A client has a chest tube inserted immediately after surgery for a left lower
lobectomy. During the repositioning of the client during the first postop check,
the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber
of the chest drain system. What is the appropriate nursing action?
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be
released into the chest drain when the client changes position this soon after surgery. The dark color of
the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected
within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the
drainage exceeds 100 mL/hr, the nurse should call the surgeon.
Ref # 1623 A client is transported to the emergency department after a motor
vehicle accident. When assessing the client 30 minutes after admission, the nurse
notes several physical changes. Which finding would require the nurse's
immediate attention? Tracheal deviation
Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension
pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build,
collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to
the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency,requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the
pressure.
Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would
expect the client to be treated with oral pancreatic enzymes and which type of
diet? High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to
prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for
osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten
intolerance, not CF, needs a gluten-free diet.
Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24
hours after surgical repair of a fractured femur. The child is crying and reports
having severe pain. The right foot is pale and there is no palpable pulse. What
action should the nurse take first? Notify the health care provider Pain and absence of a pulse
within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This
condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood
flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency.
Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.
Ref # 1927 The nurse is examining a 2 year-old child with a tentative diagnosis of
Wilm's tumor. The nurse would be most concerned about which statement by the
mother?
"Urinary output seems to be less over the past two days."
Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a
recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction.
Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate
intervention by the nurse.
Ref # 1370 A child is treated with succimer for lead poisoning. Which of these
assessments should the nurse perform first? Check complete blood count (CBC) with
differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning.
Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia.
Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ
Ref # 1773The client with a T-2 spinal cord injury reports having a "pounding"
headache. Further assessment by the nurse reveals excessive sweating, rash,
pilomotor erection, facial flushing, congested nasal passages and a heart rate of
50. What action should the nurse take next? Check the client for bladder distention and the
urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This
response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any
noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal
impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. Thestimulus creates an exaggerated response of the sympathetic nervous system and can be a life-
threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and
relieve the cause of the stimulus.
Ref # 2144 A 67 year-old client is admitted with substernal chest pressure that
radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI).
What should be the priority nursing diagnosis for this client during the first 24
hours? Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as
an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions
should be directed toward promoting tissue perfusion and oxygenation. The other problems are also
relevant, but tissue perfusion is the priority.
Ref # 1740An external disaster has occurred in the town. The triage nurse from
the emergency department is transported to the site and assigned to triage the
injured. Which of these clients would the nurse tag as "to be seen last" by the
providers at the scene? A middle-aged person with deep abrasions that are over 90% of the body
The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are
usually treated as second or third degree burns because the fluid loss is great.
ref # 1750The nurse is caring for a client who is in the advanced stage of multiple
myeloma. Which action should be included in the plan of care? Careful repositioning
Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This
disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes
hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of
bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk
of pathological fractures.
Ref # 2332
The nurse is teaching the client with chronic renal failure (CRF) about
medications. The client questions the purpose of taking aluminum hydroxide.
What is the best explanation for the nurse to give the client about the therapeutic
effects of this medication? It decreases serum phosphate Aluminum binds phosphates that tend
to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney.
Antacids such as Amphojel are commonly used to decrease serum phosphate.
Ref # 1771The nurse is caring for a client in the late stages of amyotrophic lateral
sclerosis (ALS). Which finding would the nurse expect? (Stephen hawkins)
Shallow respirations ALS is a chronic progressive neurodegenerative disease that affects nerve cells in
the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sendingmessages to muscles; all muscles under voluntary control eventually weaken and atrophy. People
eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's
mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch.
Ref # 1625 A nurse is caring for a client two hours after a right lower lobectomy.
During the assessment of the chest drainage unit (CDU), the nurse notes
bubbling in the water-seal chamber. What is the first action the nurse should
take? Assess the chest tube dressing, tubing and drainage system The first action the nurse should
take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in
the water-seal chamber right after surgery indicates an air leak from the pleural space; this is a common
finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the CDU,
such as a loose connection or a leak around the insertion site. Other nursing actions will include
assessing the color and amount of the drainage and assessing the lungs. After the initial post-operative
period, the nurse will assist the client to change positions and cough and deep breath to help re-expand
the lung and promote fluid drainage.
Ref # 1551Today's prothrombin time for a client receiving warfarin 20 seconds.
The normal range listed by the lab is 10 to 14 seconds. What is an appropriate
nursing action? Recognize that this is a therapeutic level For the client on warfarin therapy, this
prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually 1 1/2 to 2
times the normal levels.
Ref # 1599 The nurse is teaching a client with coronary artery disease about
nutrition. What information should the nurse be sure to emphasize Avoid large and
heavy meals Eating large, heavy meals can pull blood away from the heart for the digestion process. This
may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is
limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the
size of the meal, which is more important.
Ref # 1749 The client, who is receiving chemotherapy through a central venous
access device (CVAD) at home, is admitted to the intensive care unity (ICU) with
a diagnosis of sepsis. Which of the following nursing interventions is the priority?
Prepare the client for insertion of a new CVAD Many cases of sepsis occur in immunocompromised
clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source
of the infection, it should be cultured and removed. A new central line (usually an internal jugular or
subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The
new central line will also allow venous access for labs, medications and measuring central venous
pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help
guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent
infections to help protect all clients.
Ref # 1525 The client is scheduled for coronary artery bypass. Based on principles
of teaching and learning, what is the best initial approach by the nurse during
pre-op teaching? Assess the client's learning style As with any anticipatory teaching, assessment ofthe client's level of knowledge and learning style should occur first. If possible, the three senses of
hearing, seeing and touching should be used during any teaching to enhance recall
Ref # 1246 During assessment of orthostatic vital signs on a client with
cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased
from 145 to 110 mm Hg between the supine and upright positions while the heart
rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports
feeling lightheaded when standing up. The nurse should implement which of the
following actions? Instruct client to increase fluid intake for several hours This client is experiencing
postural hypotension, a decrease in systolic blood pressure 15 mm Hg accompanied by an increase in
heart rate 15 to 20 beats above the baseline with a change in position from supine to upright. This is
often accompanied by lightheadedness. Fluid replacement is appropriate, but must be instituted very
cautiously, as this client with cardiomyopathy will also be very sensitive to changes in fluid status and
fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for
one to two hours, the client should be reassessed for resolution of the postural hypotension.
Ref # 1595 The nurse is caring for a client diagnosed with acute angina. The client
is receiving an intravenous infusion of nitroglycerin. What is the priority
assessment during this treatment? Blood pressure the vasodilatation that occurs as a result of
this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15
minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV
nitroglycerin also require continuous ECG monitoring.
Ref # 2159 A client, admitted to the unit because of severe depression and suicidal
threats, is placed on suicidal precautions. The nurse should be aware that the
danger of the client committing suicide is greatest at what period of time?
When the client's mood improves with an increase in energy level Suicide potential is often increased
when there is an improvement in mood and energy level. At this time ambivalence is often decreased
and a decision is made to commit suicide. The clients have the energy to carry through with the plan for
suicide.
Ref # 1815 A mother asks about expected motor skill development for her 3 year-
old child. Which activity is considered a typical motor skill for the 3 year-old?
Riding a tricycle Three year-old children are developing gross motor skills that require large muscle
movement. While there will always be some variation between children, movement milestones typically
include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with
both feet. The other activities listed require more coordination and are movement milestones for older
children
Ref # 1539 The nurse needs to accurately assess gastric placement of a nasogastric
tube prior to the administration of an enteral feeding. What is the priority action
the nurse should take before starting the infusion? Check the pH of the aspirate Once the
initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate
before administering medications or enteral feeding solutions. Current practice recommendationsinclude assessing the feeding tube placement by testing the pH of aspirates, measuring the external
portion of the tube, and observing for changes in the volume and appearance of feeding tube aspirates.
If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that
are no longer recommended.
Ref # 2339 There is an order to administer intravenous gentamicin three times a
day. What diagnostic finding indicates the client may be more likely to
experience a toxic side effect of this medication? High serum creatinine Gentamicin is
excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An
elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for
toxicity. Reduced renal function will delay the excretion of many medications.
Ref # 1582 A nurse is working in an OB-GYN clinic. A 40 year-old woman in the
first trimester of an unplanned pregnancy provides a health history to the nurse.
Which information should receive priority attention? She has been taking an ACE
inhibitor for her blood pressure for the past two years. A report by the client that she has been taking
medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors,
commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic
effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications
and who are planning a pregnancy should be switched to medications that are not harmful to the
developing fetus before they begin trying to get pregnant.
Ref # 2266 The nurse is providing information to a client about a prescribed
medication. Which one of these statements, if made by a client, indicates that
teaching about propranolol (Inderal) has been effective? "I can have a heart attack if I
stop this medication suddenly." Propranolol is commonly used to treat hypertension, abnormal heart
rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers.
Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart
attack.
Ref # 1644 The nurse is developing a teaching plan for parents on safety and risk-
reduction in the home. Which of the following should the nurse give priority
consideration to during teaching? Age of children in the home Age and developmental level of
the child are the most important considerations in the provision of a framework for anticipatory
guidance associated with safety, and should be given priority when teaching safety.
Ref # 1312 The client is prescribed dexamethasone by mouth every other day and
asks the nurse for more information about the medication. What information
would the nurse want to share with the client? (Select all that apply)
Take the medication with food
Do not get any immunizations or skin tests
Mark your calendar to keep track of doses
Dexamethasone is a glucocorticosteroid used for its anti-inflammatory properties. It is best to take the
medication in the morning, before 9:00 am, with food or milk to avoid stomach upset. A low-sodium diet
is usually prescribed because the drug can cause an elevation in blood pressure, salt and waterretention, and increased potassium loss. Dexamethasone also causes calcium loss; the client should
increase calcium in the diet and take a calcium supplement. Because the medication affects the immune
system, it could make vaccinations ineffective and/or lead to serious infections. It's always a good idea
for clients to keep track of medication administration, particularly when they are not taking the
medication every day.
Ref # 2419 A nurse is providing care to a primigravida whose membranes
spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal
vital signs were within normal limits, she was dilated to 2 centimeters, and the
baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is
now reassessing the client. Which of these assessment findings may be an early
indication that the client is developing a complication of the labor process? Fetal
heart rate is 188 beats/minute Prolonged ruptured membranes may lead to maternal infection (as
suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188;
fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign
of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and
administer oxygen and intravenous fluids.
Ref # 2247 The registered nurse (RN) is planning the care of an 80-year-old client
with skin abrasions from a fall in the home. What aspect of this client's care is
the primary responsibility of the nurse? Perform a head-to-toe assessment The RN is
responsible to conduct a thorough assessment and evaluation of all body systems for this client. The
nurse would document information collected during the focused assessment, such as changes in skin
color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility.
Ref # 1650 A 15 year-old client has been placed in a Milwaukee brace. Which
statement made by the client is incorrect and indicates a need for additional
teaching? "I will only have to wear this for six months." The brace must be worn long-term, during
periods of growth, usually for one to two years. It is used to correct scoliosis, the lateral curvature of the
spine.
Ref # 1629 The nurse, who is participating in a community health fair, assesses the
health status of attendees. When would the nurse conduct a mental status
examination? As part of every health assessment A mental status assessment is a critical part of
baseline information and should be a part of every examination.
Ref # 1520 A nurse is talking by telephone with a parent of a 4 year-old child who
has chickenpox. Which approach demonstrates appropriate teaching by the
nurse? Papules, vesicles and crusts will be present at one time All three stages of the chickenpox
lesions will be present on the child's body at the same time. Children should not be medicated with
aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to
two days before their blisters appear and remain contagious until all the blisters have crusted over.Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter
hydrocortisone creams can help relieve itchy skin
Ref # 5280 During a yearly health screening, a 54 year-old female reports having
irregular menstrual cycles, mood swings and hot flashes. She requests a more
natural approach to manage these symptoms of perimenopause. What education
about non-pharmacological interventions will the nurse include in client
teaching? (Select all that apply.)
"You should drink at least 8-10 glasses of water a day."
"Yoga may help you manage stress and relieve symptoms."
"Incorporate more vegetables and legumes in your diet."
"Use deep breathing exercises when you start having a hot flash." Measures that
have been found to be effective in helping manage symptom of hot flashes include exercise, stress
reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a
warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal
breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the
number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine.
Eating a more plant-based diet can also help.
Ref # 1776
A nurse uses the New Ballard Scale to assess gestational age of a newborn. The
assessment score total is very high. What is a reasonable interpretation of this
result? The baby is post-term Birth weight and gestational age are important indicators of the
newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help
differentiate, for example, between a small for gestational age baby and one that is premature. The New
Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6
neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower
scores; higher scores correlate with post-maturity. Fetal distress during labor can result in lower scores.
Ref # 5307 A new task force has been created at a hospital to address a recent
increase in patient falls. The first meeting is scheduled with members from
several departments. Which of the following statements by the nurse leader
indicate intent to increase meeting effectiveness? (Select all that apply.)
"During our meeting today we will share the information we have on falls."
"Let's discuss when next we should meet and what information we will bring."
"Please introduce yourselves and your departments."
"Let's focus on the number of falls first and then we can talk about staffing." A leader increases
meeting effectiveness by not permitting one person not to dominate the discussion, encouraging
brainstorming, encouraging others to further develop ideas and helping to engage the team in future
discussions. An effective team leader will periodically summarize the information and ensure that all
ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the
meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand
and to demonstrate respect team members' other commitments.Ref # 1728 A nurse is reviewing laboratory results on a client diagnosed with acute
renal failure. Which lab result should be reported immediately? Serum potassium 6
mEq/L (6 mmol/L) Although all of these findings are abnormal, the elevated potassium level 3.5 to 5.0 is
a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia
include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (hemoglobin less
than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women) is common with kidney
disease. Blood urea nitrogen (BUN) will be increased in acute renal failure (7 to 30 mg/dL [2.5 to 10.7
mmol/L] is a considered normal).
Ref # 2290 A client taking isoniazid for tuberculosis (TB) asks the nurse about the
side effects of this medication. The client should be instructed to report which of
these findings? Extremity tingling and numbness Peripheral neuropathy is a common side effect of
isoniazid and other antitubercular medications and should be reported to the health care provider. Daily
doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid useRef # 1304 A nurse is caring for a client diagnosed with chronic obstructive
pulmonary disease (COPD) and who becomes dyspneic. The nurse should take
which action? Assist the client with pursed-lip breathing Pursed-lip breathing should be encouraged
during periods of dyspnea in COPD to control rate and depth of respiration, to prevent alveolar collapse
and to improve respiratory muscle coordination. Clients with COPD are usually on lower doses of oxygen,
titrated to maintain an oxygen saturation of 88-91%. Semi-Fowler's position is usually most comfortable
for someone with COPD, because this position allows the client's diaphragm to expand KEYWORDS
COPD, dyspnea, pursed-lip breathing
Ref # 2242 A nurse is working with one licensed practical nurse (LPN) and a
mental health tech (an unlicensed assistive personnel). Which newly admitted
client would be appropriate to assign to the mental health tech? A middle-aged client
diagnosed with an obsessive compulsive disorder The mental health tech (a type of unlicensed assistive
personnel or UAP) can be assigned to care for a client with a chronic condition after an initial assessment
by the nurse. This client has minimal risk of instability of condition and has a situation of expected
outcomes.
Ref # 4439 The client with cancer is being treated with a biological response
modifier. Which of the following side effects does the nurse anticipate with
biologic therapy? Chills and fever …uses vaccines Biological response modifier cancer therapy
agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense
mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side
effects of this type of therapy. The other assessment findings are not what you would expect when the
body is fighting pathogens.Ref # 1237 A client is admitted with severe injuries resulting from an auto
accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory
rate of 28. What should be the initial nursing intervention? Administer oxygen as
ordered Early findings of shock are associated with hypoxia and manifested by a rapid heart rate and
rapid respirations. Therefore, oxygen is the most critical initial intervention; the other interventions are
secondary to oxygen therapy.
Ref # 1356 A nurse is teaching a client to select foods rich in potassium to prevent
digitalis toxicity. Which choice indicates the client understands this dietary
requirement and recognizes which foods are highest in potassium? Baked potato A
baked potato contains 610 milligrams of potassium. Apricots, oranges and bananas do have higher
potassium content, but because of their size they are not the highest in potassium. A baked potato is the
highest in potassium of the given options.
Ref # 1446 The nurse is evaluating a developmentally challenged 2 year-old child.
During the evaluation, what goal should the nurse stress when talking to the
child's mother? Promote the child's optimal development
Ref # 1775 A newborn who is delivered at home and without a birth attendant is
admitted to the hospital for observation. The initial temperature is 95 F (35 C)
axillary. The nurse should recognize that cold stress may lead to what
complication? Reduced partial pressure of oxygen in arterial blood (PaO2) Hypothermia and cold
stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic
acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such
circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to
increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to
99.3 F (36.5 C to 37.3 C).
Ref # 1727 A client has returned from a cardiac catheterization that was two hours
ago. Which finding would indicate that the client has a potential complication
from the procedure? No pulse in the affected extremity Loss of the pulse in the extremity would
indicate a potential severe spasm of the artery or clot formation to the extent of an occlusion below the
site of insertion. It is not uncommon that initially the pulse may be intermittently weaker from the
baseline. However, a total loss of the pulse is a nursing emergency. The health care provider needs
immediate notification.
Ref # 1756 The nurse is providing discharge teaching to a client who has had a
total hip prosthesis implanted. During teaching, the nurse should include which
content in the instructions for home care? Do not cross your legs at the ankles or kneesavoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down
and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the
hip joint. This increases the risk of a malfunction of the prosthesis where the ball may pop out. A walker
or crutches may be used as assistive devices. These and other precautions are minimally followed for six
weeks postoperative and sometimes longer as indicated.
Ref # 4511Two members of the interdisciplinary team are arguing about the plan
of care for a client. Which action could any one of the members of the team use
as a de-escalation strategy? Bring the communication focus back to the client refocuses attention
on the client's care, instead of the manner of communication. It is the most effective strategy because it
is an example of collaboration.
Ref # 2258The charge nurse is making assignments for the shift. Which of these
clients would be appropriate to assign to a licensed practical nurse (LPN)? An
older adult client diagnosed with cystitis and has an indwelling urethral catheter most stable client is the
one diagnosed with cystitis. Care for this client has predictable outcomes and there is only a minimal risk
for complications. The other clients require more complex care and independent, specialized nursing
knowledge, skill or judgment that only an RN can provide.
Ref # 1529A nurse is teaching a class on human immunodeficiency virus (HIV)
prevention. Which activity should be cautioned against since it is shown to
increase the risk of HIV Engaging in unprotected sexual encounters HIV is spread through
exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest
risks
Ref # 1557 A young adult seeks treatment in an outpatient mental health center.
The client tells the nurse: "I am a government official being followed by spies."
On further questioning, the client reveals: "My warnings must be heeded to
prevent nuclear war." Which of the following actions should the nurse take? Listen
quietly without comment demonstrate grandiose ideas. The most therapeutic response is to listen but to
also avoid being pulled into the client's delusional system. At some point validation of the present
situation will need to be done. Confrontation at this time would be an inappropriate action and is not
therapeutic
Ref # 2213 Following an alert of an internal disaster and the need for beds, the
charge nurse is asked to list the clients who can potentially be discharged. Which
one of these clients should the charge nurse select? An adult client, diagnosed with type 1
diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis
type 1 diabetes is the only one with a chronic condition who has been treated for more than a day and
whose condition is the most stable
ef # 2025 Nursing students are reviewing the various types of oxygen delivery
systems. Which oxygen delivery system is the most accurate? The Venturi maskThe most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti
Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask
and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the
concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the
concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system
is 55%
Ref # 1864 A client has had a positive reaction to purified protein derivative
(PPD). When the client asks, "What does this mean?" the nurse should respond
with which statement? "You have been exposed to the organism Mycobacterium tuberculosis."
the PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy
person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates
that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a
chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum
cytology test is the only definitive test to confirm a diagnosis of active TB.
Ref # 2016 A pregnant client, at 34-weeks gestation, is diagnosed with a pulmonary
embolism (PE). Which of these medications does the nurse anticipate the health
care provider will initially order? Heparin infusion to maintain the aPTT at 1.5 to 2 times the
control value intravenous unfractionated heparin (UFH). The client's activated partial thromboplastic
time (aPTT) should be monitored and kept in the therapeutic range of between 1.5 to 2 times the
baseline value. Alternatively, low molecular weight heparins, such as enoxaparin (Lovenox), can be used
to treat PE in women who are pregnant. Warfarin should never be given during pregnancy due to its
teratogenic effects
Ref # 2445 At the beginning of the shift, the nurse is reviewing the status of each of
the assigned clients in the labor and delivery unit. Which of these clients should
the nurse check first? An adolescent who is 18-weeks pregnant with a report of no fetal heart
tones and is coughing up frothy sputum The 18 year-old client has an actual complication of left-sided
heart failure and a possible stillborn birth. The other clients present with findings of potential, but not
actual, complications.
Ref # 1676 the nurse is preparing to administer albuterol inhaled to a 11 year-old
with asthma. Which assessment by the nurse indicates there is a need for the
health care provider to adjust the medication? Apical pulse of 112 common adverse effects
of beta adrenergic medications such as albuterol (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA), is
an increase in heart rate. Normal resting heart rate for children 10 years and older is the same as adults:
60-100 beats per minute
Ref # 1920 A 3 year-old has just returned from surgery for application of a hip
spica cast. What nursing action will be the priority? Apply waterproof plastic tape to the
cast around the genital area keep it clean and dry. Shortly after returning from surgery, waterproofplastic tape will be applied around the genital area to prevent soiling. The child should be turned every
two hours to help facilitate drying, from side to side and front to back, with the head elevated at all
times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off).
After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer
(set to cool) may be used to help dry the cast.
Ref # 1530 A nurse is teaching adolescents about sexually transmitted diseases.
What should the nurse emphasize is the most common infection? Chlamydia
Ref # 1847 The respiratory technician arrives to draw blood for arterial blood gas
(ABG) analysis. What should the nurse understand about the procedure? Firm
pressure is applied over the puncture site for at least five minutes after the sample is drawn The radial
artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is
receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very
important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes.
Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma
may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical
reactions in the blood.
ef # 1250 A client has just received an extracorporeal shock-wave lithotripsy
(ESWL) procedure. What is the priority information the nurse should teach ?
"Drink 3,000 to 4,000 mL of fluid each day for one month." Drinking three to four quarts (3,000 to 4,000
mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent
formation of new calculi.
Ref # 1553 A client has received two units of whole blood today after an episode of
gastrointestinal bleeding. Which laboratory report should the nurse be sure to
monitor closely? Hemoglobin and hematocrit The post-transfusion hematocrit provides
immediate information about red cell replacement and if there is any continued blood loss; the follow-
up hematocrit should be checked around 4 to 6 hours after the infusion is completed.
ef # 1992 A group of nurses on a unit are discussing stoma care for clients who
have had a stoma made for fecal diversion. Which stomal diversion poses the
highest risk for skin breakdown? Ileostomy which is from the small intestine, is of continuous,
liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on
skin can denude skin in a few hours.
Ref # 1653 The nurse is caring for a 4 year-old child with a greenstick fracture. In
explaining this type of fracture to the parents, the best comment by the nurse
should include which point?"Bones of children are more porous than adults' and often have incomplete breaks." his allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side develops an incomplete fracture.
Ref # 1890 The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care, and all staff are invited to participate in the study if they wish. This affirms which ethical principle? Autonomy free to make
participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act. [Show Less]