All Clients Need (0201-0400)

Question 1

After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should the nurse do first?

Answer 1

Assess the irrigation catheter for patency and drainage.

Question 2

A 16-year-old girl visits the clinic for the first time. She tells the nurse that she has been exposed to herpes. Initially, with primary genital or Type 2 herpes simplex, the nurse should expect the girl to have:

Answer 2

burning or tingling on vulva, perineum, or vagina.

Question 3

An elderly client with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities; he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, “If my neighbor puts up a fence, I’ll blow him away with my shotgun. He has never respected my property line and I’ve had it!” Which of the following actions should the nurse take?

Answer 3

Report the comment to the neighbor, the daughter, and the police because there is the potential for a criminal act.

Question 4

A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?

Answer 4

Ask for the prescription to be changed to oral gastric tube.

Question 5

Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills?

Answer 5

Determining if the client’s physical condition is life-threatening

Question 6

A young school-age child whose mother and aunt have bipolar disorder and whose father has depression is brought to the child psychiatrist’s office by her father. He has custody of the child since the parents divorced. The father says that the child has problems with behavior, attention in school, and sleeping at night. The child says “My brain doesn’t turn off at night.” The psychiatrist diagnoses the child with attention deficit hyperactivity disorder (ADHD) with a possibility of bipolar disorder as well. What should the office nurse say to the father to reinforce what the psychiatrist said? Select all that apply.

Answer 6

• “The psychiatrist diagnosed your child with ADHD because of her attention and behavior problems at school.”
• The psychiatrist is considering a bipolar diagnosis because of your child’s family history of bipolar disorder and her sleep issues.”
• “ADHD involves difficulty with attention, impulse control, and hyperactivity at school, home, or in both settings.”

Question 7

While caring for a pregnant adolescent, a nurse should develop a care plan that incorporates the adolescent’s:

Answer 7

level of emotional maturity.

Question 8

Which client best fits into the middle-old elderly population?

Answer 8

A 76-year old with hypertension

Question 9

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

Answer 9

Airborne and contact precautions

Question 10

When a nurse is assessing a client for pain, what finding is most significant? The client:

Answer 10

Tells the nurse about experiencing pain.

Question 11

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:

Answer 11

assess the client for pain.

Question 12

A nurse is changing a dressing and providing wound care. Which activity should she perform first?

Answer 12

Wash her hands thoroughly.

Question 13

A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?

Answer 13

Encouraging intake of at least 2 L of fluid daily

Question 14

A mother of a 4-year-old child asks the nurse how to talk with her daughter about strangers. The little girl is very friendly and her mother is concerned that her child could be abducted. The nurse should tell the mother:

Answer 14

to talk with her daughter about what she should do if a stranger talks to her.

Question 15

The nurse is caring for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first?

Answer 15

Switch the transfusion to normal saline solution.

Question 16

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?

Answer 16

Elevated temperature.

Question 17

After a laminectomy, the client states, “The physician said that I can do anything I want to.” Which of the following client-stated activities indicates the need for further teaching?

Answer 17

Sweeping the front porch.

Question 18

The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:

Answer 18

I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.

Question 19

The nurse identifies the type of presentation shown in the figure as which of the following?

Answer 19

Complete breech.

Question 20

A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

Answer 20

methadone.

Question 21

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action?

Answer 21

Receiving a portion of the revenue to improve client services on the unit

Question 22

A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?

Answer 22

Report back to the nurse immediately if any client has an output less than 240 ml.

Question 23

A staff nurse on the mental health unit tells the nurse manager that kids with conduct disorders might as well be jailed because they all end up as adults with antisocial personality disorder anyway. What is the best reply by the nurse manager?

Answer 23

You sound really frustrated. Let’s talk about the meaning of their behavior.

Question 24

The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?

Answer 24

• Security tags in place.
• Identification system on mother and infant.
• Someone in room able to care for infant.
• Bulb syringe within sight.

Question 25

A client asks the nurse why the prostate specific antigen (PSA) level is determined before the digital rectal examination. The nurse’s best response is which of the following?

Answer 25

A prostate examination can possibly increase the PSA.

Question 26

While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, “What are these white dots in my baby’s mouth? I tried to wash them out, but they’re still there.” After assessing the neonate’s mouth, the nurse explains that these spots are which of the following?

Answer 26

Epstein’s pearls.

Question 27

The client with glaucoma is scheduled for a hip replacement. Which of the following prescriptions would require clarification before the nurse carries it out?

Answer 27

Administer atropine sulfate.

Question 28

A nurse is assigned to a client who, after a medication teaching session with her, began receiving amitriptyline (Elavil) to treat depression. One week after starting this drug, the client refuses to take the medication. He says it has caused blurred vision, dry mouth, and constipation, but it hasn’t improved his mood. Which nursing diagnosis is appropriate for this client?

Answer 28

Deficient knowledge (treatment regimen) related to inadequate understanding of teaching

Question 29

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because:

Answer 29

Status epilepticus may develop.

Question 30

A client is brought to the mental health center for an evaluation by a police officer because she has been bothering other people when she eats in the hotel restaurant. She denies this, will not give her name, and holds tightly to her purse. She refuses to talk to anyone except to say, “You have no right to keep me here. I have money, and I can take care of myself.” Which of the following factors would be most relevant to a decision about this client’s disposition?

Answer 30

She seems able to care for herself.

Question 31

When a father asks if his 5-year-old son should have the Denver Developmental Screening Test (DDST), which of the following information should the nurse obtain to respond to the father?

Answer 31

Father’s understanding of the test.

Question 32

The physician has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse contacts the physician to discuss the potential for:

Answer 32

Increased intraocular pressure.

Question 33

A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal?

Answer 33

Maintaining effective respirations

Question 34

While attending a support group, the parents of a child with hemophilia become concerned because several of the families have had older children who have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which of the following as the most likely route of transmission of AIDS to these children?

Answer 34

Contamination of the factor VIII replacement received during bleeding episodes.

Question 35

When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which of the following as the basis for the discussion?

Answer 35

Autosomal recessive gene.

Question 36

Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?

Answer 36

Tomato juice.

Question 37

A client’s membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she’s worried about her baby. Which response by a nurse is best?

Answer 37

Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission.

Question 38

A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Answer 38

Ensure adequate hydration before the anesthetic is administered.

Question 39

A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should:

Answer 39

Monitor the client for signs of pneumothorax.

Question 40

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Answer 40

Cullen’s sign

Question 41

A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?

Answer 41

Your child will need less blood work as his glucose levels stabilize.

Question 42

Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?

Answer 42

Avoid shaving with straight-edge razors.

Question 43

After working multiple shifts in the psychiatric intensive care unit, a nurse recognizes that she’s becoming more distant and, at times, even irritable. The best action for the nurse to take would be to:

Answer 43

talk with the charge nurse and seek support from her peers on the unit.

Question 44

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?

Answer 44

Metabolic alkalosis and hypokalemia

Question 45

The nurse has been instructing the client about how to prepare meals that are low in fat, cholesterol, and sodium. Which of these comments would indicate the client needs additional teaching?

Answer 45

”I’ll eat more liver with onions.”

Question 46

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for:

Answer 46

ensuring that the suspected child abuse is reported to local authorities.

Question 47

The nurse-manager is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.

Answer 47

• Admission to the hospital.
• Transfer to the nursing home.
• Admission to a home health agency from the hospital.
• Transfer of a client from surgery to the surgical unit

Question 48

Three years ago, a client was diagnosed with multiple sclerosis. He now presents with lower extremity weakness and heaviness. During the admission process, the client presents his advance directive that states he doesn’t want intubation, mechanical ventilation, or tube feedings, should his condition deteriorate. How should the nurse respond?

Answer 48

It’s important for us to have this information. You should review the document with your physician at every admission.

Question 49

The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on:

Answer 49

Providing an over-the-bed cradle to protect the left ankle from the pressure of bed linens.

Question 50

A client scheduled for a vasectomy asks the nurse how soon after the procedure he can have sexual intercourse without using an alternative birth control method. How should the nurse respond?

Answer 50

You can safely have unprotected intercourse when your sperm count indicates sterilization.

Question 51

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

Answer 51

Tretinoin (retinoic acid [Retin-A])

Question 52

A client with bladder cancer has lost an estimated 500 ml blood in the urine. The client’s hemoglobin is 8.0 g/dl, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:

Answer 52

Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing.

Question 53

The parent of a young adult client diagnosed with paranoid schizophrenia is asking questions about his son’s antipsychotic medication, ziprasidone (Geodon). Which of the following statements by the father reflects a need for further teaching?

Answer 53

I should give him benztropine to help prevent constipation from the ziprasidone.

Question 54

The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first:

Answer 54

Place the child in a croup tent.

Question 55

A nurse is caring for a client with anorexia nervosa who has a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to dysfunctional eating patterns. Which interventions are supportive for this client? Select all that apply.

Answer 55

• Monitor weight gain.
• Encourage the client to keep a journal.
• Monitor the client during meals and for 1 hour after meals.
• Provide small, frequent meals.

Question 56

The nurse is caring for an infant of an insulin-dependent diabetic primiparous client. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which of the following?

Answer 56

Interrupted supply of maternal glucose and continued high neonatal insulin production.

Question 57

A major role in crisis intervention is getting a client’s significant others involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize which of the following?

Answer 57

Emergency resources and when to use them

Question 58

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Answer 58

Monitoring the patency of an indwelling urinary catheter

Question 59

After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond?

Answer 59

Provide the information requested.

Question 60

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:

Answer 60

onto the bedpan.

Question 61

A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?

Answer 61

Increase your carbohydrate intake.

Question 62

When witnessing an adult client’s signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.

Answer 62

• That there was adequate disclosure of information.
• That the client has full awareness of the potential complications.
• That the client understood the information.
• That there was voluntary consent on the client’s part.

Question 63

When a nurse assesses a 2-year-old child with suspected dehydration, which condition should be reported to the physician immediately?

Answer 63

Decreased blood pressure

Question 64

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

Answer 64

Droplet precautions

Question 65

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to:

Answer 65

install safety devices in the home.

Question 66

A nurse is reviewing a pregnant client’s nutritional status. To determine whether she has an adequate intake of vitamin A, the nurse should assess her diet for consumption of:

Answer 66

milk.

Question 67

A multigravid client at 36 weeks’ gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, “My boyfriend has been beating me up once in a while since I became pregnant–but I can’t bring myself to leave him because I don’t have a job and I don’t know how I would take care of my other children.” Which of the following actions should be the priority by the nurse at this time?

Answer 67

Help the client make concrete plans for the safety of herself and her children.

Question 68

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:

Answer 68

3 full days of elevated basal body temperature and clear, thin cervical mucus.

Question 69

A client diagnosed with anxiety disorder is ordered buspirone (BuSpar). Teaching instructions for buspirone should include:

Answer 69

a warning about the drug’s delayed therapeutic effect, which occurs in 14 to 30 days.

Question 70

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following?

Answer 70

Antibodies are not usually formed until after exposure to an antigen.

Question 71

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include:

Answer 71

delayed gastric emptying.

Question 72

A primigravida, currently about 8 weeks pregnant, and her husband, ask their primary care provider when they should begin the preparation for childbirth classes that discuss maternal and newborn nutrition during pregnancy. Which of the following times would be most appropriate for the nurse to suggest that they begin the classes?

Answer 72

Now during the first trimester of pregnancy.

Question 73

Which nursing action is most appropriate to include in the plan of care for a dying child to meet the child’s emotional needs during the last days of life?

Answer 73

Answer the child’s questions about illness and death honestly.

Question 74

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

Answer 74

Prescription drug intoxication.

Question 75

A client seeks care for lower back pain of 2 weeks’ duration. Which assessment finding suggests a herniated intervertebral disk?

Answer 75

Pain radiating down the posterior thigh

Question 76

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

Answer 76

wash her hands after touching the client.

Question 77

A charge nurse completing a deceased client’s chart audit notes that the chart contains a copy of the client’s advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses’ notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to “Discontinue code blue due to existing advanced directives and DNR from client.” What does the charge nurse conclude? Select all that apply.

Answer 77

• The physician was correct to stop resuscitation efforts.
• By calling a code blue, the nurse disregarded the client’s advance directives and DNR order.

Question 78

When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS) the nurse should teach about which of the following measures? Select all that apply.

Answer 78

• Maintain a smoke-free environment.
• Breast-feed the baby.
• Place the baby on his back to sleep.

Question 79

Which action should a nurse perform immediately following the birth of a neonate?

Answer 79

Drying the neonate to stabilize the neonate’s temperature

Question 80

A client with a long history of dissociative identity disorder is admitted to the unit after cuts on her legs are sutured in the emergency department. During the admission interview, the client tearfully states that she does not know what happened to her legs. Then a stronger, alter personality states that the client is useless, weak, and needs to be eliminated completely. The nurse should do which of the following?

Answer 80

Contract with the alter personality to tell the nurse when he has the urge to harm the client and the body they both share.

Question 81

A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first?

Answer 81

Formally report her concerns to the nurse-manager.

Question 82

Which statement by the parent of a child with polycystic kidney disease and stage 2 renal disease indicates the need for more teaching?

Answer 82

My child will outgrow this disease.

Question 83

Following a total hip replacement, the nurse should do which of the following? Select all that apply.

Answer 83

• Use a fracture bedpan when needed by the client.
• When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.
• Encourage the client to use the overhead trapeze to assist with position changes.

Question 84

The most effective measure the nurse can use to prevent wound infection when changing a client’s dressing after coronary artery bypass surgery is to:

Answer 84

Observe careful hand-washing procedures

Question 85

A nurse is administering sublingual nitroglycerin (Nitrostat) to a client. Immediately after administering nitroglycerin, the nurse should expect to administer:

Answer 85

acetaminophen (Tylenol).

Question 86

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, “If I could be with my people, I could receive acupuncture for this pain.” The nurse should understand that acupuncture in the Asian culture is based on the theory that it:

Answer 86

Restores the balance of energy.

Question 87

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?

Answer 87

Removing the initial dressing for incision inspection

Question 88

The client with an Axis I diagnosis of schizophrenia, undifferentiated type, is acutely psychotic and exhibits religious delusions and hallucinations, loose associations, and concrete thinking. When the nurse offers the client her medication, the client states, “I don’t need that. God will heal me.” The nurse should respond to the client by saying:

Answer 88

God is important in your life, but the medicine will help you too.

Question 89

A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client’s disturbed thought process?

Answer 89

I think these thoughts are frightening to you.

Question 90

Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?

Answer 90

Advising the client to eat large amounts of cheese.

Question 91

In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics?

Answer 91

Disturbances in cognition and consciousness that fluctuate during the day.

Question 92

The nurse has given a client a nitroglycerin tablet sublingually for angina. Which of the following vital signs should be assessed following administration of nitroglycerin?

Answer 92

Blood pressure.

Question 93

Which of the following should the nurse expect to find in a premature female neonate born at 30 weeks’ gestation who is small for gestational age?

Answer 93

Fine, downy hair over the upper arms and back.

Question 94

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin?

Answer 94

Cephalosporins

Question 95

A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client?

Answer 95

Administer bronchodilators as prescribed.

Question 96

A nurse is giving discharge instructions to a parent of a 13-month-old infant who weighs 18 lb (8.2 kg). The nurse knows the parent understands car-seat safety when the parent states:

Answer 96

My infant may ride in a front-facing car seat as soon as he weighs 21 pounds.

Question 97

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital “to visit a friend.” The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting “chest pain.” Place the nurse’s actions in priority order.

Answer 97

• Contact the security department.
• Obtain an EKG.
• Obtain a prescription for a urine sample.
• Initiate a referral to obtain drug rehabilitation counseling.

Question 98

After assessing a client, a nurse formulates relevant nursing diagnoses. Which statement is a complete nursing diagnosis statement?

Answer 98

Ineffective airway clearance related to mucus plugs and nonproductive cough

Question 99

A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate’s birth because:

Answer 99

the neonate will be responsive and eager to suck at this time.

Question 100

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he’s had a problem with unstable blood glucose levels in the past. Based on the client’s history, he should be referred to which health care worker?

Answer 100

Dietitian

Question 101

Which measure must a graduate nurse take before working on the antepartum unit?

Answer 101

Complete facility and unit orientation

Question 102

The nurse is caring for an elderly client who has experienced a sensorineural hearing loss. The nurse anticipates that the client will exhibit which one of the following symptoms?

Answer 102

Difficulty hearing high-pitched sounds.

Question 103

Which of the following responses is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?

Answer 103

When you interrupt others, they leave the area.

Question 104

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:

Answer 104

Vertigo.

Question 105

When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000 ml/day, which of the following fluids should the nurse consider as most appropriate for the client’s condition and effective for preventing excessive thirst?

Answer 105

Ice chips.

Question 106

After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet?

Answer 106

Roast beef.

Question 107

The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?

Answer 107

Don clean gloves and wipe up the drops of liquid.

Question 108

A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy?

Answer 108

Because your surgery does not involve other organs or tissues, you’ll likely not notice much change in your sexual performance.

Question 109

A client has been diagnosed with Avoidant Personality Disorder. He reports loneliness, but has fears about making friends. He also reports anxiety about being rejected by others. In designing a long-term treatment plan, in what order, from first to last, should the nurse include the following?

Answer 109

• Talk with the client about his self-esteem and his fears.
• Teach the client anxiety management and social skills.
• Help the client make a list of small group activities at the center he would find interesting.
• Ask the client to join one of his chosen activities with the nurse and 2 other clients.

Question 110

A client is recovering from an acute myocardial infarction (MI). During the first week of the client’s recovery, the nurse should stay alert for which abnormal heart sound?

Answer 110

Pericardial friction rub

Question 111

While repositioning an immobile client, a nurse notes that the client’s sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it’s most appropriate for the nurse to:

Answer 111

document the condition of the client’s skin.

Question 112

An otherwise-healthy adolescent is hospitalized for diabetic ketoacidosis and is receiving I.V. and oral fluids. The nurse should monitor his fluid intake because quick fluid replacement or fluid overload may cause:

Answer 112

cerebral edema.

Question 113

The charge nurse on the postpartum unit has received report about a client with a fetal demise who has just delivered and will be ready for transfer out of Labor and Delivery in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?

Answer 113

Talk to the mother first and decide on a location that is mutually agreeable.

Question 114

The plan of care for a client with hypertension taking propranolol hydrochloride should include:

Answer 114

Instructing the client to notify the physician of irregular or slowed pulse rate.

Question 115

Several minutes after a vaginal birth, nursing assessment reveals blood gushing from the client’s vagina, umbilical cord lengthening, and a globular-shaped uterus. The nurse should suspect which condition?

Answer 115

Placental separation

Question 116

A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization?

Answer 116

The parents.

Question 117

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?

Answer 117

Remain supine for the time specified by the physician.

Question 118

Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn’s disease?

Answer 118

Promoting bowel rest.

Question 119

In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks’ gestation is in the left occipitoanterior (LOA) position?

Answer 119

Below the umbilicus on the left side.

Question 120

A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained:

Answer 120

until three fecal cultures are negative for Shigella.

Question 121

A child who is admitted after having suffered trauma has also been exposed to varicella. Which of the following should the nurse institute for infection control?

Answer 121

Airborne precautions.

Question 122

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?

Answer 122

By positioning the neonate so that the head remains still

Question 123

A client in the emergency department complains of suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is assessing the client to determine treatment recommendations. The most important factor to consider is:

Answer 123

whether the client has an active suicide plan and the means to carry it out.

Question 124

Following an eclamptic seizure, the nurse should assess the client for which of the following?

Answer 124

Uterine contractions.

Question 125

Which performance improvement strategy helps prevent adverse reactions to blood products?

Answer 125

Confirming client identification with two qualified health professionals

Question 126

There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.

Answer 126

• Place each item of clothing in a separate paper bag.
• Hang wet clothing to dry.

Question 127

A client is being admitted to a psychiatric outpatient program for counseling for his ongoing emotional symptoms. He is asked to rate the severity of his depression, anxiety and anger. He states, “I don’t have any anger any more. I lost my temper once and nearly hurt my wife. I never got angry again.” In which order of priority from first to last should the following principles related to anger be shared with this client?

Answer 127

• “Anger is a natural emotion occurring in all human relationships.”
• “Unexpressed anger has a negative effect on the human body and mind.”
• “Holding your anger inside contributes to your depression.”
• “You can learn effective ways to discuss anger with others and still maintain control.”

Question 128

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant’s parents are Catholic and do not want the surgery to take place unless the infant has first been baptized. The nurse asks the parents:

Answer 128

Do you want me to help arrange the baptism?

Question 129

The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which of the following to minimize the rise in blood glucose level after meals?

Answer 129

Dietary fiber.

Question 130

The client is taking fluoxetine (Prozac) 20 milligrams at bedtime. The drug is not helping the client sleep. The nurse should conclude that:

Answer 130

The client should take Prozac in the morning.

Question 131

The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children:

Answer 131

have thinner skin than adults.

Question 132

Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?

Answer 132

Monitoring intake and output.

Question 133

After delivering a viable neonate 12 hours ago, the client’s fundus is firm at midline and her breasts are soft. She has scant lochia and a negative Homans’ sign. The client reports pain in her lower back. Which of the following should the nurse do next?

Answer 133

Administer an ordered mild analgesic.

Question 134

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client’s lesions?

Answer 134

Vesicles

Question 135

A 38-year-old female client with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which of the following actions should the nurse suggest?

Answer 135

See the physician immediately.

Question 136

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information?

Answer 136

Fifth disease is transmitted by respiratory secretions.

Question 137

Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic?

Answer 137

Administering meperidine (Demerol).

Question 138

A client with primary (essential) hypertension is taking chlorothiazide (Diuril). The nurse determines teaching about this medication is effective when the client makes the following statement. “I will:” (Select all that apply.)

Answer 138

• Not drink alcoholic beverages while on this medication.
• Take my weight daily at the same time each day.
• Reduce salt intake in my diet.
• Avoid prolonged exposure to sunlight.

Question 139

A woman at 22 weeks’ gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client?

Answer 139

Refer the client to her health care provider for evaluation and treatment of the pain.

Question 140

During an extremely busy shift on the psychiatric unit, a newly graduated nurse approaches the charge nurse and states, “I’m having a hard time taking care of mentally ill people. What can I do to handle this stress?” The charge nurse’s best response is:

Answer 140

Maybe we could schedule a time to discuss this further.

Question 141

When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan?

Answer 141

Cardiac output increases by 25% to 50% during pregnancy.

Question 142

During the emergent (resuscitative) phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation?

Answer 142

Serum creatinine level of 2.5 mg/dl.

Question 143

A client who is 1-day postpartum following delivery of a viable neonate asks the nurse about resuming sexual activity. After giving instructions, the nurse determines that the client understands the instructions when she says:

Answer 143

“Sexual intercourse may be resumed about 3 to 4 weeks postpartum.”

Question 144

A client has had a cast applied to the arm. Which of the following home care instructions would be appropriate for cast care? The client should:

Answer 144

Smell the cast for foul odors.

Question 145

When developing the teaching plan for an adolescent with insulin-dependent diabetes, what should the nurse include about the relationship among exercise, diet, and insulin?

Answer 145

If your blood glucose is 240 mg/dl or above, do not run.

Question 146

A mother reports she cannot afford the antibiotic azithromycin (Zithromax), which was prescribed by the physician for her toddler’s otitis media. The nurse’s best response is to:

Answer 146

Confer with the physician about whether a less expensive drug could be ordered.

Question 147

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Answer 147

Urine output of 20 ml/hour

Question 148

If a client’s central venous catheter accidentally becomes disconnected, what should a nurse do first?

Answer 148

Clamp the catheter.

Question 149

Rho(D) immune globulin (RhoGAM) is ordered for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following?

Answer 149

Development of Rh-positive antibodies.

Question 150

After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially?

Answer 150

Invite the client to go for a walk with the nurse and one other client.

Question 151

Which finding from a laboratory report is most indicative of aplastic anemia?

Answer 151

A decreased hemoglobin.

Question 152

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse’s assessment and interventions, what would be the most desirable outcome?

Answer 152

The student accepts a referral to a substance abuse counselor.

Question 153

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy is most effective for this illness?

Answer 153

Behavior therapy.

Question 154

Which of the following is the priority for a client with a fractured femur who is in traction?

Answer 154

Prevent effects of immobility while in traction.

Question 155

To avoid injury while caring for a client, which principle is most important for a nurse to apply when implementing care?

Answer 155

Bending and twisting while providing care may cause injury.

Question 156

The nurse is preparing an educational program on breast cancer for women at an African American community center. What information is important for the nurse to consider for the discussion?

Answer 156

Breast cancer concerns vary between socioeconomic levels of African American women.

Question 157

When discussing the onset of adolescence with parents, the nurse explains that it occurs at which of the following times?

Answer 157

1 to 2 years earlier in girls than in boys.

Question 158

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?

Answer 158

To prevent vision loss

Question 159

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, boardlike abdomen. The nurse should do which of the following first?

Answer 159

Notify the physician.

Question 160

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Answer 160

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release

Question 161

Knowing Maslow’s hierarchy of needs can assist a nurse in understanding a client’s behavior. Place the stages of Maslow’s hierarchy of needs in order from basic to most complex. Use all options.

Answer 161

• Physiologic needs
• Safety and security
• Love and belonging
• Self-esteem
• Self-actualization

Question 162

The mother asks the nurse about using a car seat for her toddler who is in a hip spica cast. The nurse should tell the mother:

Answer 162

You will need a specially designed car seat for your toddler.

Question 163

Assessment of a 15-year-old primigravid client at term in active labor reveals cervical dilation at 7 cm with complete effacement. The nurse should assess the client for which of the following first?

Answer 163

Cephalopelvic disproportion (CPD).

Question 164

A client presents to the obstetrician’s triage center with no prenatal care and painless, bright red vaginal bleeding. Which interventions are most indicated?

Answer 164

Applying an external fetal monitor and performing a complete physical assessment.

Question 165

Which infection control equipment is necessary for the client diagnosed with Clostridium difficile diarrhea?

Answer 165

Gloves

Question 166

The nurse is assisting with a bone marrow aspiration and biopsy. Place the following tasks in the order in which the nurse should perform them, from highest priority to least priority:

Answer 166

• Verify the client has signed an informed consent.
• Position the client in a side-lying position.
• Clean the skin with an antiseptic solution.
• Apply ice to the biopsy site

Question 167

Which of the following indicates a potential complication of diabetes mellitus?

Answer 167

Blood pressure of 160/100 mm Hg.

Question 168

A full-term client is admitted for induction of labor. When admitted, her cervix is 25/0. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?

Answer 168

Dinoprostone (Cervidil).

Question 169

A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:

Answer 169

Ensure that the catheter is draining freely.

Question 170

A nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?

Answer 170

Hanging the irrigation bag 24″ to 36″ (60 to 90 cm) above the stoma

Question 171

A parent asks the nurse about the nutritional needs of her toddler. Which of the following responses by the nurse would be most appropriate?

Answer 171

“Toddlers have definite food preferences.”

Question 172

A client who is allergic to penicillin has a prescription to receive cefazolin (Ancef). The nurse’s initial response is to:

Answer 172

Ask if the client has taken cefazolin before.

Question 173

A primigravid client at 32 weeks’ gestation is enrolled in a breast-feeding class. Which of the following statements indicate that the client understands the breast-feeding education? Select all that apply.

Answer 173

• “I need to feed my baby when I see feeding cues and not wait until she is crying.”
• “If I breast-feed, my uterus will return to prepregnancy size more quickly.”
• “I can hold my baby several different ways during feedings.”

Question 174

Which of the following toys should the nurse give to a toddler to use in the hospital playroom?

Answer 174

Blocks.

Question 175

A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate?

Answer 175

Encourage more fluid intake.

Question 176

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the nurse add?

Answer 176

Related to bone demineralization resulting in pathologic fractures

Question 177

A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first?

Answer 177

Hand the fork to the client and say, “Use this fork to eat your green beans.”

Question 178

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client’s bedside?

Answer 178

Suction machine with catheters

Question 179

A manager of an outpatient clinic is explaining the various health care delivery systems to a client who’s interested in joining a system with a reasonable fixed capitation rate. Which organization is the client primarily interested in joining?

Answer 179

A health maintenance organization (HMO)

Question 180

A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery?

Answer 180

72 hours.

Question 181

A 25-year-old has been diagnosed with hypertrophic cardiomyopathy. The nurse should assess the client for:

Answer 181

Fatigue and shortness of breath.

Question 182

A nurse has an order to administer an I.M. injection using the Z-track technique. When carrying out this order, what should the nurse do?

Answer 182

Simultaneously withdraw the needle and release the skin.

Question 183

Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to take at home. What is the expected outcome of giving this drug?

Answer 183

Binding phosphate in the intestine.

Question 184

A client who weighs 187 lb has an order to receive enoxaparin (Lovenox) 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters?

Answer 184

0.85

Question 185

As part of the respiratory assessment, a nurse observes the neonate’s nares for patency and mucus. The information obtained from this assessment is important because:

Answer 185

neonates are obligate nose breathers.

Question 186

An elderly client becomes confused, dislodges his I.V. access, and attempts to remove his indwelling urinary catheter. The client’s primary nurse calls the physician and receives an order for soft wrist restraints. When the client’s family insists that he not be restrained, the charge nurse informs the family that the family must provide an around-the-clock attendant for the client in order to avoid restraints. The family spokesman replies, “You find the attendant; that is your responsibility.” It would be most appropriate for the charge nurse to respond:

Answer 186

I recommend family members arrange to stay with the client.

Question 187

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?

Answer 187

Intradermal drugs diffuse more slowly.

Question 188

The nurse is administering prednisone to a child with nephrosis. To assure that the nurse has identified the child correctly, the nurse should do which of the following. Select all that apply.

Answer 188

• Check the child’s identification band against the medical record number.
• Verify the date of birth from the medical record with the date of birth on the client’s identification band.

Question 189

A client with type 1 diabetes takes 15 units of Humulin N insulin before breakfast and 8 units before dinner. During a follow-up visit, the nurse reevaluates the client’s knowledge about insulin therapy and self-administration skills. The nurse realizes the client requires additional teaching when she discovers the client takes which over-the-counter preparations?

Answer 189

Salicylate-containing preparations

Question 190

Which of the following hospitalized clients is at risk to develop parotitis?

Answer 190

An 80-year-old client who has poor oral hygiene and is dehydrated.

Question 191

A dystonic reaction can be caused by which medication?

Answer 191

Haloperidol (Haldol)

Question 192

During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:

Answer 192

histrionic personality disorder.

Question 193

The nurse is observing a new graduate nurse instill eyedrops into a client’s eyes. The nurse evaluates that the new graduate is using appropriate technique when which of the following steps is incorporated into the procedure?

Answer 193

The nurse’s hand is stabilized on the client’s forehead while instilling the drops.

Question 194

The primary health care provider orders fluoxetine (Prozac) orally every morning for a 72-year-old client with depression. Which transient adverse effect of this drug requires immediate action by the nurse?

Answer 194

Dizziness.

Question 195

Laboratory studies indicate a client’s blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client’s glucose use?

Answer 195

Serum glycosylated hemoglobin (Hb A1c)

Question 196

After vaginal delivery of a term neonate, the nurse determines that the placenta is about to separate when which of the following occurs?

Answer 196

A sudden gush of dark blood occurs.

Question 197

A client with amebiasis, an intestinal infection, is ordered metronidazole (Flagyl). When teaching the client about adverse reactions to this drug, the nurse should mention:

Answer 197

metallic taste.

Question 198

A pregnant mother who has brought her toddler to the clinic for a check-up asks the nurse how she can keep her next baby from becoming obese. The mother plans to bottle-feed her next child. Which information should the nurse include in the teaching plan to help the mother avoid overnourishing her infant?

Answer 198

Recognizing clues indicating that a baby is full.

Question 199

A nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:

Answer 199

should begin the day after surgery.

Question 200

A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife’s impending death from aggressive breast cancer. The nurse should:

Answer 200

Begin education about strategies for communication with his children.