All Clients Need (0601-0800) Flashcards
(200 cards)
1
Q
During a Preparation for Parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” The nurse should tell the participant which of the following about true labor contractions?
A
True labor contractions are felt first in the lower back, then the abdomen.
2
Q
A 14-month-old child has a severe diaper rash. Which of the following recommendations should the nurse provide to the parents?
A
Wash the buttocks using mild soap.
3
Q
A nurse is preparing to palpate a client’s thyroid gland. Which action by the nurse is appropriate?
A
Encircle the client’s neck with both hands, have the client slightly extend his neck, and ask him to swallow.
4
Q
A nurse observes that decerebrate posturing is a comatose client’s response to painful stimuli. Decerebrate posturing as a response to pain indicates:
A
dysfunction in the brain stem.
5
Q
The primary goal in the plan of care for the client after cataract removal surgery is to:
A
Promote safety at home.
6
Q
Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed?
A
Nurses who are pregnant must wear gloves during administration of cytotoxic drugs.
7
Q
A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
A
Respiratory isolation
8
Q
The client has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?
A
I don’t think about killing myself as much as I used to.
9
Q
A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis?
A
Sadness
10
Q
The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
A
Sitting all afternoon in her room.
11
Q
A primigravid client visits the clinic at 12 weeks’ gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using:
A
Saline nose drops.
12
Q
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following problems should receive the highest priority during the acute phase?
A
Ineffective breathing pattern related to neuromuscular impairment.
13
Q
A client with Alzheimer’s disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which of the following statements?
A
Dad said that what he missed most while he was here was using his aftershave.
14
Q
The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has:
A
Reduced intestinal peristalsis.
15
Q
When observing the client in a ritualistic pattern of behavior, the nurse should:
A
Allow the client to continue so that he will not become more anxious.
16
Q
When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client’s anxiety?
A
As a precaution, we wear gowns, goggles, and gloves to administer the medication.
17
Q
Which of the following is appropriate language development for an 8-month-old? The child should be:
A
Saying “dada” and “mama” nonspecifically.
18
Q
The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to:
A
Prevent dislocation of the prosthesis.
19
Q
After a bronchoscopy with biopsy, the nurse assesses the client. Which of the following signs should be reported immediately to the physician?
A
Laryngeal stridor.
20
Q
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
A
The operative incision is near the diaphragm.
21
Q
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse’s priority intervention?
A
Discuss meals that include low-fat high-carbohydrate content.
22
Q
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
A
Providing a solution of viscous lidocaine for use as a mouth rinse
23
Q
A community health nurse is asked to consult with the family of a 4-year-old boy who is often disruptive at preschool, difficult to engage, and rarely speaks. When upset, the client flaps his arms and screeches. Which of the following questions and comments would be appropriate for the nurse to make to the parents? Select all that apply.
A
- “Has a pediatrician evaluated your child? He seems to have some abnormal behaviors for his age.”
- “How does your child behave at home? If you do not see acting-out behavior there, part of his problem may be dealing with new situations, such as school.”
- “How do you respond if he disobeys or acts out at home? If your techniques help prevent negative behavior, perhaps teachers can try similar measures at school.”
24
Q
A nurse is caring for a client 24 hours after an abdominal-perineal resection for a bowel tumor. The client’s wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
A
Auscultate for bowel sounds.
25
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output
26
A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
Place a tongue blade lightly on the posterior aspect of the pharynx.
27
Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
Auscultation of moist crackles.
28
Which step should a nurse take first when administering a liquid medication to an infant?
Verify the physician order.
29
A client chronically complains of being unappreciated and misunderstood by others. He is argumentative and sullen. He always blames others for his failure to complete work assignments. He expresses feelings of envy toward people he perceives as more fortunate. He voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?
Passive-aggressive personality
30
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
Place the client in a private room.
31
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?
Temperature of 102° F (37.7° C)
32
A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care?
Increasing the need for antianxiety agents
33
Which of the following would the nurse do after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?
Apply gentle pressure to the site with a sterile gauze pad.
34
A multigravid client diagnosed with chronic hypertension is now in preterm labor at 34 weeks' gestation. The primary health care provider has ordered magnesium sulfate at 3 grams/hour. Which assessment finding indicates that the intended therapeutic effect has occurred?
Decrease in the frequency and number of contractions.
35
A client with bipolar disorder has been taking lithium carbonate (Lithonate), as prescribed, for the past 3 years. Family members have brought this client to the hospital. The client hasn't slept, bathed, or changed clothes for 4 days; has lost 10 lb (4.5 kg) in the past month; and woke the entire family at 4 a.m. with plans to fly them to Hawaii for a vacation. Based on this information, the nurse understands that:
the client's lithium level should be measured before he receives the next lithium dose.
36
Sulfamethoxazole has been prescribed to treat a client’s urinary tract infection. The initial dosage is 2 g orally. The nurse has 500-mg tablets available. How many tablets should the nurse give?
4
37
When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should recommend?
Take the prednisone with food.
38
A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
Apply deodorant only under the left arm.
39
The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information?
Lack of weight bearing causes demineralization of the long bones.
40
A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which of the following responses by the nurse is most appropriate?
Most clients can resume their normal meal patterns in about 6 to 12 months.
41
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan?
Increased risk for urinary tract infections.
42
A client with a history of heart failure is receiving a lidocaine (Xylocaine) I.V. infusion at 2 mg/minute to treat runs of ventricular tachycardia. The client experiences hypotension, dyspnea, and irregular heartbeats. Which action can the nurse expect the physician to take first?
Decreasing the lidocaine infusion to 1 mg/minute
43
A nurse is teaching a client about nonpharmacologic comfort measures to alleviate postoperative pain. Which client statement indicates a need for further teaching?
With patient-controlled analgesia, or PCA, I can control my pain by administering my own pain medication.
44
A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction?
Dystonia
45
A client taking lithium is ordered citalopram (Celexa) for panic disorder. Five days after starting the citalopram, the client reports sweating and feelings of anxiety, restlessness, and confusion. The nurse suspects the client is experiencing:
serotonin syndrome.
46
Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner?
Conduct a class for clients who require the same discharge teaching.
47
The client is advised by the physician to have mammography screening annually. Measures to improve adherence with mammography screening include:
Making sure that the individual barriers to screening are minimized.
48
A primipara calls the birthing unit 3 days after a vaginal delivery. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which of the following instructions would be appropriate?
Use ice packs for 20 minutes every 3 to 4 hours.
49
A client who had a colectomy 8½ hours ago and has received 1,500 ml of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
Dim the lights in the room.
50
A client with obsessive-compulsive disorder follows a complicated bedtime routine that includes the use of a nightlight. A nurse notes this behavior in the care plan and passes on the information at change of shift. When the nurse returns the next day, the client states that she's very upset because someone turned off her nightlight. When the nurse investigates, she finds that a newly hired nurse had cared for the client. What would be the nurse's best course of action?
Ask the night nurse about her experience of caring for client the previous night.
51
The nurse is caring for a client who has been placed on droplet precautions. Which of the following protective gear is required to take care of this client? Select all that apply.
* Surgical mask
* Gown
* Gloves
* Glasses
52
A client who's receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply.
* Avoid crowded places such as shopping malls.
* Avoid people who have recently received attenuated vaccines.
* Wash hands frequently.
* Avoid activities that may cause bleeding
53
A primigravid client who was successfully treated for preterm labor at 30 weeks' gestation had a history of mild hyperthyroidism before becoming pregnant. The nurse should instruct the client to do which of the following?
Continue taking low-dose oral propylthiouracil (PTU) as ordered.
54
The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which of the following views most perpetuates the stigma?
Clients can recover from mental illness if they have willpower.
55
A nurse is performing a neurologic assessment on a neonate. Which sign is considered a normal finding in a neonate?
Positive Babinski's reflex
56
While caring for a post-term multigravida who is being induced with intravenous oxytocin (Pitocin) solution, which of the following findings should the nurse interpret as indicative of a possible complication?
Convulsions.
57
During the initial stage of adaptation to the diagnosis of cancer and its treatment, the nurse can facilitate the client's adaptation by:
Encouraging the client to maintain her usual role.
58
According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal?
Improving the staff's use of restraint procedures.
59
After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?
Maintaining traction continuously to ensure its effectiveness
60
The nurse is taking care of a client who has an I.V. infusion pump. The pump alarm rings. What should the nurse do in order from first to last?
* Silence the pump alarm.
* Assess the client’s access site for infiltration or inflammation.
* Assess the tubing for hindrances to flow of solution.
* Determine if the infusion pump is plugged into an electrical outlet
61
A client is receiving chemotherapy for brain cancer. When teaching the client and his wife about contamination from excretion of the chemotherapy drugs, the nurse should instruct the wife and client that:
Any contaminated linens should be washed separately and then washed a second time, if necessary.
62
A nurse is caring for a child with leukemia. Which goal is a priority?
Monitoring the child's temperature.
63
Sequential compression therapy is to be used postoperatively on a client's legs. The nurse must take which action first when the client returns to the room?
Confirm the client's identity using two client identifiers.
64
When assessing a child with muscular dystrophy, the nurse expects which finding?
Waddling gait
65
The hospital where a client plans to give birth asks her to provide signed documents before delivery. The client asks the nurse to explain what an advance directive is. What is the nurse's best response?
It's a legal document that helps establish and verify your health care wishes in the event that you can't speak for yourself or your infant.
66
A 20-year-old obese primigravida at 40 weeks' gestation is admitted to the birthing center in the first stage of labor with contractions lasting 50 seconds and occurring every 3 to 4 minutes. The client's cervix is dilated 5 cm and is 75% effaced. When assessing the client's emotional status, which of the following should the nurse anticipate the client to exhibit?
Seriousness.
67
A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The primary health care provider prescribes treatment with risperidone (Risperdal) to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which of the following?
Apathy, affect, social isolation.
68
Which nursing action is most appropriate in preventing an adverse reaction to total parenteral nutrition (TPN)?
Use an infusion pump to administer the TPN solution.
69
A 10-year-old girl visits the clinic for a checkup before entering school. The child's mother questions the nurse about what to expect of her daughter's growth and development at this stage. Which response is appropriate?
Friends will be very important to her, and she'll develop an interest in the opposite sex.
70
A client with Buerger's disease smokes two packs of cigarettes a day. Smoking cessation is critical or the client may lose the affected extremity. When helping a client change behavior, it is important to know the client's:
Perception of the negative behavior.
71
A nurse understands that for the parathyroid hormone to exert its effect, what must be present?
Adequate vitamin D level
72
The guidelines for evaluating registered nurse professional conduct are contained in the:
Standards of Care.
73
Which intervention should the nurse employ to reduce trauma caused during vaccine administration to a 6-month-old infant?
Simultaneously administer vaccines at separate sites.
74
A nurse is preparing a staff education program about pulmonary circulation. Place the options below in the order that matches the path of pulmonary circulation. Use all options.
* Right ventricle
* Pulmonary artery
* Arterioles and alveoli
* Pulmonary vein
* Left atrium
75
A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?
The oxygen tubing is pinched.
76
After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?
Empty the urinary appliance when one-third full.
77
While meeting with the nurse, a client's wife states, "I don't know what else to do to make him stop drinking." The nurse should refer the wife to which of the following organizations?
Al-Anon.
78
The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective?
Asocial behavior and anergia.
79
An infant, age 6 weeks, is brought to the clinic for a well-baby visit. To assess the fontanels, how should the nurse position the infant?
Seated upright
80
A client has a testicular nodule that is highly suspicious for testicular cancer. A laboratory test that supports this diagnosis is:
Increased AFP.
81
In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a desired outcome for the client? The client will:
Maintain current weight.
82
A primigravid client at 8 weeks' gestation tells the nurse that she doesn't like milk. To ensure that the client consumes an adequate intake of milk products, the nurse should instruct the client that an 8-oz glass of milk is equal to which of the following?
1½ to 2 slices of presliced American cheese.
83
A client is admitted to the oncology unit with an infection. It is suspected that the infection may be related to their vascular access device (VAD). The nurse should draw the blood cultures from which of the following sites?
A peripheral site and all lumens of the VAD.
84
A nurse is providing dietary teaching for the parents of a child with celiac disease. Which statement by the parents indicates effective teaching?
Our child should avoid eating prepared puddings.
85
A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. Which of the following responses by the nurse overhearing the conversation would be best?
Talking to the staff member privately about this.
86
A client with chronic renal failure plans to receive a kidney transplant. Recently, the physician told the client that he is a poor candidate for transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now, the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply.
* Take a seat next to the client and sit quietly.
* Say to the client, "You're feeling upset about the news you got about the transplant.
87
Which factor should be checked when evaluating the effectiveness of an alpha-adrenergic blocker given to a client with benign prostatic hyperplasia (BPH)?
Voiding pattern
88
Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?
Electrocardiogram (ECG).
89
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response?
Newborns typically move their whole body in response to pain.
90
The nurse is discussing a treatment plan for mononucleosis with an adolescent. The nurse emphasizes that the client must:
Avoid contact sports and vigorous exercise for 2 to 4 weeks.
91
A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to:
a perinatologist.
92
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?
Protest.
93
A multiparous client visits the urgent care center 5 days after a vaginal delivery experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, “Why am I continuing to bleed like this?” The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following?
Retained placental fragments.
94
A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?
The nurse should follow facility procedures for reporting an error.
95
The nurse should warn a client who is taking a benzodiazepine about using which of the following medications in combination with his current medication?
Antacids.
96
A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible?
Hypokalemia
97
A client admitted to the unit with a diagnosis of end-stage renal disease is scheduled to undergo hemodialysis. He voices anxiety over shunt placement and management of care at home. A nurse initiates a referral to which members of the interdisciplinary team?
Home health nurse, nutritionist, and social worker
98
A nurse admits a client who presents with symptoms of severe depression and a diagnosis of rapid cycling bipolar disorder. Several hours later, the client is pacing in the hall and asks the nurse to determine if he has a fever. His vital signs are: blood pressure of 148/90 mm Hg, pulse of 133 beats/minute, respirations of 24 breaths/minute, temperature of 99.2.° F (37.3° C). What do these assessment findings suggest?
The client needs further evaluation for illness.
99
An extremely agitated client is brought to the psychiatric unit by her husband. He reports that she has been hospitalized several times for treatment of bipolar disorder and has spent thousands of dollars in the past week. The psychiatrist admits her to the unit for exacerbation of the manic phase of bipolar disorder. Which approach by the nurse promotes a therapeutic relationship with this client?
Maintaining a firm but nonthreatening manner
100
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning
101
Lomotil has been prescribed to treat a client’s diarrhea. The nurse should teach the client to report which of the following common side effects?
Urine retention.
102
A primigravid client at 35 weeks' gestation is scheduled for a biophysical profile. After instructing the client about the test, which of the following, if stated by the client as one of the parameters of this test, indicates effective teaching?
Amniotic fluid volume.
103
The client with major depression and suicidal ideation has been taking bupropion (Wellbutrin) 100 mg P.O. four times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which of the following behaviors?
Suicide attempt.
104
An adolescent in the early stages of labor is admitted to the labor and delivery unit. The nurse notes lymphadenopathy and a macular rash on the palmar surfaces of the hands and plantar surfaces of the feet. Admission laboratory testing reveals trace ketones in the urine, white blood cell count 10,000/μl, hemoglobin 14.5 g/dl, hematocrit 40%, and the nontreponemal antibody test is positive. The nurse notifies the physician of the laboratory results. Which action by the nurse takes priority?
Consulting with the infection control nurse.
105
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?
Avoid stimulants and alcohol for 24 to 48 hours before the test.
106
A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/minute. The nurse should do which of the following in order from first to last?
* Affirm airway obstruction by the tube.
* Deflate the tube by cutting with bedside scissors.
* Remove the tube.
* Apply oxygen via face mask.
107
In a small rural facility, a nurse is caring for a neonate born to a mother with diabetes mellitus. The neonate's respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, and oxygen saturation is 92% on room air. The nurse obtains a blood glucose level, which is 50 mg/dl. Realizing the seriousness of the neonate's condition, the pediatrician arranges transfer to a level III nursery. The social worker asks the nurse what transportation arrangements are needed. What type of transportation is required?
Medical helicopter sent to the rural facility from the level III facility
108
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day?
Prone.
109
A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply.
* Interpretation of the fetal monitor strip.
* Support persons with the client.
* Prior delivery history.
* Amount of vaginal bleeding or discharge.
* Analgesia or anesthesia being used.
110
A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.
111
A client with a cocaine dependency is irritable, anxious, highly sensitive to stimuli, and over-reactive to clients and staff on the unit. Which of the following actions is most therapeutic for this client?
Providing the client with frequent "time-outs."
112
The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
170 calories.
113
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which of the following?
Effects of analgesic medication.
114
A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
Insertion of a chest tube into the neonate.
115
A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?
Lubricant jelly
116
The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:
A booster is recommended before college even if she had the vaccine a few years ago.
117
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing.
118
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.
* Encourage the client to keep a journal.
* Provide small, frequent meals.
* Monitor the client during meals and for 1 hour after meals.
* Monitor weight gain.
119
A client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the care plan?
Telling the client of the nurse's concern for her health and desire to help her make decisions to keep herself healthy
120
A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child's left leg is immobilized in a splint. What is an appropriate expected outcome for this child?
The child will change position with minimal discomfort.
121
The client is admitted to the hospital for alcohol detoxification. Which of the following interventions should the nurse use? Select all that apply.
* Explaining to the client that the symptoms of withdrawal are temporary.
* Monitoring intake and output.
* Taking vital signs.
* Reinforcing reality if the client is disoriented or hallucinating.
122
After teaching the mother of an 18-month-old child being discharged with a prescription for co-trimoxazole (Bactrim), which of the following statements by the mother would indicate the need for additional teaching?
I should give the medicine after he eats some food.
123
When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize?
Diabetes mellitus
124
The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which of the following indicates goals of therapy have been met?
Joint range of motion improved.
125
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
Latent phase
126
Which of the following findings should the nurse note in the client who is in the compensatory stage of shock?
Tachycardia.
127
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. The nurse should do which of the following next? Select all that apply.
* Notify the health care provider of the change.
* Place respiratory resuscitation equipment in the client's room.
* Check for advancing levels of paresthesia.
128
A client who's 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:
9 to 12 weeks' gestation.
129
The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has:
Decreased chest movement on the affected side.
130
Which of the following assessments provides the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?
Vital signs.
131
Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?
Inserting a Foley catheter
132
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do?
Recommend he have his blood pressure rechecked within 2 weeks.
133
The nurse is assessing a client with chronic pain. Which of the following is an expected response?
Normal vital signs, physical inactivity, and normal facial expressions.
134
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply.
* Triage priority.
* Identifying information when possible (such as name, age, and address).
* Medications and treatments administered.
135
The client is receiving 6 mg of selegiline transdermal system (Emsam) every 24 hours for major depression. The nurse should judge teaching about Emsam to be effective when the client makes which statement?
I need to avoid using the sauna at the gym.
136
A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:
The antibiotic is the only medicine necessary.
137
Which sign is an early indicator of heart failure in an infant with a congenital heart defect?
Tachycardia
138
A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. Which of the following should the nurse assess first after admission to the birthing area?
Contraction frequency and intensity.
139
After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:
Does not understand body integrity.
140
A newly hired nurse on unit orientation prepares to administer vitamin K (AquaMEPHYTON) to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best?
Stop the nurse and have her reevaluate her injection techniques.
141
In an initial screening for lead poisoning a 2-year-old child is found to have a lead level of 12 mcg/dl. The nurse should:
Educate parents on ways to reduce lead in the environment.
142
A client who experienced long-term childhood sexual abuse by his babysitter and her boyfriend is diagnosed with post-traumatic stress disorder (PTSD). He is admitted for the second time after physically assaulting a prostitute. “She is no better that my babysitter and deserves to be dead. I’d like to kill the sitter, too.” With the knowledge of the client's history and diagnosis, which of the following nursing interventions should be implemented at admission? Select all that apply.
* Institute precautions for suicide, assault, and escape.
* Ask the client to sign a "No Harm Contract."
* Provide safe outlets for his anger and rage.
* In 1-to-1 staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend.
143
The primary health care provider orders carbamazapine extended release (Tegretol-XR) for a client with a cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube, and carbamazapine is on the hospital's "no crush" list. In order to administer the medication, the nurse should:
Contact the primary care provider to change the order.
144
A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for birth, which nursing intervention is most appropriate?
Applying gentle pressure to the baby's head
145
The nurse is to assess a neonate who was delivered vaginally about 12 hours ago. At which of the following times should the nurse anticipate performing the assessment?
Midway between feedings.
146
Which characteristic is most common among suicidal clients?
Ambivalence
147
When developing a teaching plan for a group of parents with preschoolers about the most effective strategies for safety, the nurse should tell the parents to focus on:
Modeling good examples of safe behavior.
148
Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first?
What did the infant look like when you found him?
149
An adolescent tells the nurse that he would like to lose weight and asks the nurse's opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate?
Participating in an adolescent weight-reduction program.
150
A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. His family members report that he has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms?
Serum calcium level 13.8 mg/dl
151
When instructing a pregnant client diagnosed with a chlamydial infection at 28 weeks' gestation, which of the following should the nurse include about this infection during pregnancy?
She will likely receive a 10-day course of erythromycin.
152
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?
Incontinence and right-sided hemiparesis
153
A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN?
A 2-year-old child who nearly drowned 2 days earlier
154
The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following?
Distend the veins.
155
Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual?
Paternalism
156
Which of the following symptoms is common in clients with active tuberculosis?
Weight loss.
157
Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3?
Restrict staff and visitors with active infections.
158
The nurse has just received morning change-of-shift report on four assigned clients. In what order from first to last should the nurse do the following?
* Notify the physician about a client with a serum potassium level of 6.2.
* Call the physician to request an antiemetic for a client who has been vomiting.
* Discuss the plan for the day with the nursing assistant, delegating duties as appropriate.
* Begin discharge paperwork for a client with a serum potassium level of 6.2.
159
A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
One fingerbreadth below the umbilicus
160
A client with a history of hypertension and peripheral vascular disease underwent an aorto-bifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2 ° C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50-70 mL/hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends that the primary care provider:
Restarts the metoprolol.
161
A community health nurse is working with disaster relief following a flood. Finding safe housing for survivors, providing support for families, organizing counseling, and securing physical care are examples of which type of prevention?
Tertiary prevention
162
A client is receiving chrysotherapy (Myochrysine) as treatment for rheumatoid arthritis. The nurse should instruct the client to report?
Rash.
163
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has prescribed I.M. prostaglandin-F2a. After administration of the medication, the nurse should observe the client for which of the following?
Tachycardia.
164
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
Positioning the client on the side with the knees flexed
165
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
166
An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?
Diabetes mellitus is more common in Hispanics and Blacks than in Whites.
167
The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which of the following? Select all that apply.
* Copious frothy mucus.
* Episodes of cyanosis.
168
A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician orders cimetidine (Tagamet) I.V. Infusing this medication too rapidly may cause:
hypotension.
169
An 8-year-old has a body mass index (BMI) for age at the 90th percentile, but has no other risk factors. The nurse should:
Refer the family to a dietician.
170
Which statement describes the rationale for administering vitamin K to every neonate?
The neonate lacks intestinal flora to make the vitamin.
171
A 16-year-old primigravid client admitted at 38 weeks' gestation with severe preeclampsia is given intravenous magnesium sulfate and lactated Ringer's solution. The nurse should obtain which of the following information?
Respiratory rate every hour.
172
A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:
providing client education at every opportunity.
173
A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, "It's that school nurse again. She's done nothing but try to make trouble for our family since my son started school. And now you're in on it." The nurse should respond by saying:
You sound pretty angry with the school nurse. Tell me what has happened.
174
When magnesium sulfate is administered to a client in labor, its action occurs at which site?
Neural-muscular junctions
175
When assessing a child with bronchiolitis, which finding does the nurse expect?
Productive cough
176
A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?
Accepting these fears and allowing the client to take a sponge bath
177
A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?
A new cast is needed every 1 to 2 weeks.
178
While assessing a 2-month-old infant's airway, the nurse finds that he isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should:
administer five back blows.
179
A home care nurse is making a visit with a client who had a double-barrel colostomy created after bowel surgery. While the nurse is changing the client's appliance, there is a knock on the door. The nurse answers the door. The client's next-door neighbor wants to visit with the client. Which intervention by the nurse is most appropriate?
Ask the neighbor to come back in 20 minutes.
180
A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia?
Magnesium and potassium
181
The client with Hodgkin's disease develops B symptoms. These manifestations indicate which of the following?
The client has night sweats.
182
A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which of the following requirements is not in place? Select all that apply.
* An I.V. line.
* Oxygen administration.
* An anesthesiologist.
* An identification band.
183
Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management? Select all that apply.
* "My baby can't have milk-based formulas."
* "We have to follow a strict phenylalanine diet."
* "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."
184
A 10-year-old child who is 5' 4" (138 cm) tall with a history of asthma uses an inhaled bronchodilator only when needed. He takes no other medications routinely. His best peak expiratory flow rate is 270 L/minute. The child's current peak flow reading is 180 L/minute. The nurse interprets this reading as indicating which of the following?
The child needs to use a short-acting inhaled beta2-agonist medication.
185
When preparing a 20-month-old with a foreign body in the nasal passage for removal of the foreign body by the health care provider, the nurse should apply a:
Papoose board.
186
Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences:
heat intolerance and systolic hypertension.
187
When performing an abdominal assessment, a nurse should follow which examination sequence?
Inspection, auscultation, percussion, and palpation
188
A client is receiving methotrexate (Trexall), 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
Leucovorin (citrovorum factor or folinic acid)
189
The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process?
You cannot have any visitors while you're here involuntarily.
190
The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
Assist the client out of bed to sit upright in a chair for 1 hour.
191
The nurse should conduct a focused assessment with the client with multiple sclerosis for the risk of which of the following? Select all that apply.
* Falls
* Skin breakdown
* Fatigue
192
A 24-year-old woman is being assessed for a malformation of the uterus. The accompanying figure indicates which of the following uterine malformations?
Bicornate uterus.
193
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply.
* "Effects of the drug continue for 4 to 5 days after discontinuing the medication."
* "I should have my blood levels tested periodically."
* "Maximum dosage is not achieved until 3 to 4 days after starting the medication."
194
The nurse who uses self-disclosure should:
refocus on the client's experience as quickly as possible.
195
A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality?
* Shred the documents or place them in a Health Insurance
* Portability and Accountability Act (HIPAA) trash container.
196
Jail staff asked for a mental health evaluation on a 21-year-old woman. The client was arrested on charges of prostitution; the request for evaluation followed after the client stabbed herself repeatedly with a fork. The evaluation revealed that she was kidnapped and held from ages 8 to 16 by a convicted child pornographer. The client said she never contacted her family after her release from captivity. The nurse should do the following in what order of priority from first to last.
* Initiate suicide precautions and a no-harm contract.
* Offer empathy and support; be nonjudgmental and honest with her.
* Encourage safe verbalizations of her emotions, especially anger.
* Ask the client if she wishes to contact her family while hospitalized.
197
If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do which of the following?
Sit in a tub of warm water.
198
A client is admitted to the emergency department with sudden onset of chest pain. Which of the following orders should the nurse implement immediately? Select all that apply.
* Administer nitroglycerin.
* Administer aspirin.
* Administer morphine.
* Provide oxygen.
199
The physician prescribes raloxifene hydrochloride (Evista) for a 60-year-old woman. The drug is effective if the client does not have:
Osteoporosis.
200
A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?
Deficient fluid volume related to osmotic diuresis
