All Clients Need (0801-1000) Flashcards
(200 cards)
1
Q
Which of the following outcomes should the nurse include in the initial plan of care for a client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and unresponsiveness to the nurse’s questions?
A
The client will interact with the nurse.
2
Q
When the open method is used for treating burns, which of the following actions should the nurse take to help prevent discomfort caused by air currents over the client’s burned skin surfaces?
A
Support the bed linens on a cradle.
3
Q
A client with cirrhosis should be encouraged to follow which diet?
A
Well-balanced normal nutrients, low-sodium diet.
4
Q
A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?
A
Playing with the child every day.
5
Q
The nurse is reviewing the chart of a 55-year-old male client who is scheduled for a lumbar laminectomy. The nurse should report which of the following to the surgeon?
A
Pimple on the lower back.
6
Q
A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
A
Bowel regimen.
7
Q
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?
A
Deficient knowledge (disease process and treatment regimen)
8
Q
When developing appropriate short-term goals with clients who are inpatients, which of the following is most realistic?
A
The client will write a list of strengths and needs.
9
Q
Four months ago, the son and daughter of a client who was in a vegetative state gave consent for a feeding tube and agreed to long-term care placement. Nurses in the long-term care facility note that the son and daughter have recently become more distraught over their mother’s condition. One day while visiting together, the son and daughter approach the nurse about having the feeding tube removed. Which statement by the nurse best explains the legal rights of individuals in this situation?
A
Legally, there are no time constraints on previous decisions made.
10
Q
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:
A
hold and rock him and give him a security object.
11
Q
Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested?
A
Ketoconazole suppresses adrenal steroid secretion.
12
Q
The charge nurse on an antepartal unit is making staffing assignments for the day. There is an RN, licensed practical nurse (LPN), and an unlicensed personnel (UAP) to care for 25 patients. The nurse should assign which of the following clients to the LPN?
A
A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4-6 hours prn while awaiting urine cultures to be returned.
13
Q
A 19-year-old unmarried college student is approximately 8 weeks pregnant asks the nurse, “If I have an abortion in the next 2 or 3 weeks, how will it be done?” The nurse instructs the client that at this gestational age an abortion is usually performed by which of the following techniques?
A
Dilatation and curettage.
14
Q
While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client’s family how to deal with it at home, what should the nurse do?
A
Irrigate the tube with cola.
15
Q
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
A
Wait until the father arrives.
16
Q
A female client who has a urinary diversion tells the nurse, “This urinary pouch is embarrassing. Everyone will know that I’m not normal. I don’t see how I can go out in public anymore.” The most appropriate nursing goal for this client is to:
A
Express fears about the urinary diversion.
17
Q
Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
A
Ask the client to identify other situations in which he demonstrated responsibility for himself.
18
Q
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the accompanying chart and compares these findings to the Apgar score obtained at birth, also found in the chart. What should the nurse do next?
A
Continue to assess the neonate.
19
Q
When developing the discharge teaching plan for a child with chronic renal failure and the family, the nurse should emphasize restriction of which of the following nutrients?
A
Phosphorus.
20
Q
The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be most appropriate for this client?
A
Ask the client’s spouse to supervise the daily administration of the medications.
21
Q
A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and doesn’t respond to verbal or tactile stimuli. In formulating nursing care interventions, the nurse should give priority to:
A
observing and evaluating the client’s nutritional needs.
22
Q
Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term?
A
Sole creases covering the entire foot.
23
Q
The mother of a 3-year-old child tells the nurse her child is “fussy” and not as “easy going” as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:
A
Provide structured feeding times and routines.
24
Q
Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?
A
Absence of tear formation.
25
The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?
Rebound hypoglycemia.
26
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
Take thyroxine replacement for the remainder of the client's life.
27
An 18-year-old tells the nurse, "Everyone does it, so it's all right," to justify rule-breaking behavior. The nurse realizes this is an example of which level or stage of moral reasoning development as described by Kohlberg?
Conventional.
28
A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply.
* T-wave inversion
* ST-segment elevation
* Pathologic Q-wave
29
An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which of the following actions should the school nurse do ?
Move the adolescent to a cool environment.
30
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors is most likely of greatest significance in causing an exacerbation of ulcerative colitis?
A demanding and stressful job.
31
A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for:
Focal ischemia.
32
An elderly client hospitalized 4 days for treatment of acute respiratory distress has become confused and disoriented. The client has been picking invisible items from blankets and yelling at a daughter who is not in the room. The family tells the nurse that the client has been treated for anxiety with Xanax (alprazolam) for years, but Xanax is not part of the client's current medication list. Which of the following safety measures should be implemented? Select all that apply.
* The client's medical and mental status will be evaluated frequently and treated as needed.
* Medications will be made available to help with the hallucinations.
* The client will be placed on withdrawal precautions and treatment immediately.
33
A nurse is giving instructions to a client with a new colostomy. The client states, “I am so tired today; I just cannot think.” The nurse should:
Reschedule the appointment at a time when the client is rested.
34
Eardrops have been prescribed to be instilled in the adult client’s left ear to soften cerumen. To position the client, the nurse must do which of the following? Select all that apply.
* Straighten the client's eustachian tube.
* Gently pull the auricle up and back.
35
A client comes to a community mental health clinic for a psychiatric evaluation at his family's request. During the initial interview, the client tells the nurse about painting the streets to beautify the city, lecturing subway riders about germ control, and banning smoking in order to clean up the environment. The client is irritable and easily distracted by the slightest sound. Which stage of mania is the client exhibiting?
Acute mania
36
Which client statement indicates that the client has coped effectively with a relationship problem?
We are really listening to each other about our different view on issues.
37
A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should:
Keep the client tobacco-free for 30 minutes before the test.
38
A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast care, the nurse should?
Use only the palms of the hand when handling the cast.
39
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test?
Total protein
40
The client who is receiving chemotherapy is not eating well but otherwise feels healthy. Which meal suggestion would be best for this client?
Broiled chicken, green beans, and cottage cheese.
41
When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands:
the client must take benztropine (Cogentin) as ordered to prevent a return of symptoms.
42
The primary health care provider has ordered intravenous mannitol (Osmitrol) for a child with a head injury. The best indicator that the drug has been effective is:
Decreased intracranial pressure.
43
A female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She's placed on trimethoprim-sulfamethoxazole (Bactrim) to treat the infection. Another medication is ordered to decrease the pain and frequency. Which is the most likely medication ordered for the pain?
Phenazopyridine (Pyridium)
44
While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first?
Note the color, amount, and odor of the amniotic fluid.
45
The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation?
Airborne precautions.
46
A client is to be discharged from an alcohol rehabilitation program. Which of the following should the nurse emphasize in the discharge plan as a priority?
Follow-up care.
47
One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse is most therapeutic?
Your behavior is disturbing to the other clients. I'll walk with you around the patio to help you release some of your energy.
48
The nurse is planning to teach incisional care to a client before discharge. Which of the following instructions should be included?
Do not be concerned about uneven lumps under the suture lines.
49
A nurse must assess a client's judgment to determine his mental status. To best accomplish this, the nurse should have the client:
discuss hypothetical ethical situations.
50
Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy?
a compromised skin graft.
51
A young man makes an appointment to see the psychiatric nurse at the Employee Assistance Program of a large corporation beacuse his female boss is sending him provocative e-mails, and making seductive remarks on his voice mail at home. The nurse informs him about Corporate Workplace Violence Guidelines and he agrees to work with Corporate Security on the issue. What should the nurse do next?
Ask the client about his reactions to this situation.
52
The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions?
Assess the family's food preferences.
53
The nurse is preparing to assist with the removal of a chest tube. Which of the following is appropriate at the site from which the chest tube is removed?
Petroleum gauze.
54
When planning home care for a 3-year-old child with eczema, what should the nurse teach the mother to remove from the child's environment at home?
Stuffed animals.
55
In the oliguric phase of acute renal failure, the nurse should assess the client for:
Pulmonary edema.
56
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?
They increase the need for insulin.
57
The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next:
Check the dressing for signs of bleeding.
58
The nurse prepares to discharge a 5-year-old child from the 1-day surgery unit. The nurse leaves the room to get supplies and then, on returning, finds that the child is not breathing. The client is pulseless, and the nurse begins chest compressions. The nurse should apply pressure:
On the lower sternum with the heel of one hand.
59
When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse should place the first priority on discussing the use of which of the following?
Child restraints in automobiles.
60
A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is:
weight.
61
An anticipated outcome for the client after cataract removal surgery would include which of the following?
The client describes methods to prevent an increase in intraocular pressure.
62
A physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guérin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
hematuria.
63
Which of the following is an early sign of laryngeal cancer?
Persistent mild hoarseness.
64
A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis?
Tachycardia
65
A 17-year-old client visits the clinic at 36 weeks' gestation. The client's blood pressure is 130/90 mm Hg. On previous visits, her blood pressure ranged from 100 to 110 mm Hg systolic, 70 to 80 mm Hg diastolic. Further assessment reveals slight edema of her hands and 1 + proteinuria. The nurse anticipates that the physician will most likely order which of the following?
Bed rest with bathroom privileges.
66
When an infant with pyloric stenosis is admitted to the hospital, which of the following should the nurse do first?
Weigh the infant.
67
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
Temperature.
68
A nurse completing her management rotation in the intensive care unit (ICU) is working with an experienced ICU nurse. One client's work supervisor calls to "check up" on the client. The nurse offers to transfer the call to the client's family members. The experienced ICU nurse recognizes this action as:
protection of the client's privacy.
69
A nurse is preparing to administer 500 ml of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/ml. At what rate should the nurse infuse the solution?
42
70
Which of the following positions would be most comfortable for a client with a ruptured disc at L5-S1 right?
Supine with the legs flexed.
71
An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?
Gown, gloves, mask, and eye goggles or eye shield
72
A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:
Bence Jones protein in the urine
73
A 13-month-old has a febrile seizure one month after the administration of the chicken pox vaccine. The nurse should:
Report the event through the CDC Vaccine Adverse Event Reporting System.
74
During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?
Assess vital signs.
75
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The primary health care provider orders manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this order based on the understanding that this action will accomplish which of the following?
Decrease intracranial pressure.
76
A client with terminal cancer tells the nurse that she is not afraid to die and she is thinking about how to plan her funeral. The most appropriate referral the nurse could suggest would be to the:
Pastoral care department.
77
Which of the following philosophies should the nurse most likely integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness?
Living each day as it comes as fully as possible.
78
A 12-year-old client says, "Give me my pajamas. I'm not putting your silly gown on." An appropriate response by the nurse should be:
You're upset because you feel awkward and embarrassed in these gowns.
79
The nurse has discussed sexuality issues during the prenatal period with a primigravida who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says:
“I should not get sexually aroused or have any nipple stimulation."
80
A 70-year-old, previously well client asks the nurse, "I notice I have tremors. Is this just normal for my age?" The best response for the nurse to make is which of the following?
You should report this to the physician because it may indicate a problem.
81
When developing the teaching plan for a primipara and her term neonate, on the first postpartum day the nurse plans to discuss neonatal reflexes. After describing the rooting reflex, which of the following, if stated by the mother as the age at which the reflex disappears, indicates effective teaching?
3 to 4 months.
82
A 76-year-old client tells the nurse that she has lived long and does not need mammograms. Which is the nurse's best response?
The incidence of breast cancer increases with age.
83
A client undergoing long-term peritoneal dialysis at home is currently experiencing reduced outflow from the dialysis catheter. To determine if the catheter is obstructed, the nurse should inquire whether the client has:
Constipation
84
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
fluid replacement.
85
An older adult has chest pain and shortness of breath. The health care provider prescribes nitroglycerin tablets. Which should the nurse instruct the client to do?
Put the tablet under the tongue until it is absorbed.
86
A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first:
Assist the client up to the toilet to attempt to void.
87
A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply.
* Rash.
* Hyperthermia.
* Muscle rigidity.
88
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see figure). The nurse should
Proceed to suction the client’s tracheostomy.
89
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the the UAP reports which of the following about one of the clients?
Evidence of spontaneous rupture of the membranes.
90
A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he's scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next?
Apply physical restraints to protect the client, then contact the physician for orders.
91
A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through:
inhalation of aerosols.
92
A nurse is assessing a neonate. Which finding suggests hypothermia?
Bradycardia
93
A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider?
Give 1 to 3 teaspoons of fluid every 10 to 15 minutes.
94
Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents? Select all that apply.
* Abdominal pain.
* Blood in the stool.
* Reduced blood clotting ability
95
A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:
has type 2 diabetes.
96
In response to the nurse's question about how a postpartum client is feeling, the client replies that she is tired, sore, and hungry. She then begins to relate her birth experience. Based on these data, the nurse determines that the client is in which phase of postpartal psychological adaptation?
Taking in.
97
A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size?
23G
98
While caring for a multigravid client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?
Yogurt.
99
The nurse is teaching a client with Parkinson’s disease about the nutritional modifications to make in the diet because the client is taking levodopa. The nurse should instruct the client to?
Avoid foods high in pyridoxine (vitamin B12).
100
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which of the following adverse effects of this medication?
Maculopapular rash.
101
When a client wants to read the chart, the nurse should:
Give the client the chart and answer questions for him.
102
A nurse is reviewing a care plan for a 10-year-old child who has recently been diagnosed with type 1 diabetes. Which instruction should the nurse remove from a teaching plan focusing on proper hygiene?
Teach blood glucose monitoring.
103
The most important long-term goal for a client with hypertension is to:
Make a commitment to long-term therapy.
104
A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg P.O. daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?
I take the medication at bedtime.
105
A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:
pulmonary crackles.
106
When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?
Dressing.
107
When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply.
* Child molesters pick those over whom they have some authority, making it easier for them to manipulate the child with special favors or attention.
* Child molesters gain a child's trust before making sexual advances so the child feels obligated to comply with sex.
* Child molesters often choose victims whose parents must work long hours, making the extra attention initially welcome by the child.
* Child molesters maintain the secrecy of their actions by threatening the child if offering attention and favors fail or if the child is close to revealing the secret.
108
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?
8 days after conception.
109
The nurse reports to the primary health care provider signs of increased intracranial pressure in an infant with a myelomeningocele who has which of the following?
A high-pitched cry.
110
When auscultating a client's abdomen, a nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:
nothing abnormal.
111
A clinic client with agoraphobia must go to a local laboratory to have blood drawn. The client is terrified, stating, "I know I can't handle being in the waiting room." What is the nurse's most therapeutic response?
I'll arrange for you to be the first client and we'll talk about it afterward.
112
A client with a diagnosis of borderline personality disorder has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at the weekly conference. Which intervention is most appropriate for the nursing staff to implement?
Rotate the nurses who are assigned to the client.
113
In providing discharge teaching for the client after a modified radical mastectomy, the nurse should instruct the client to avoid which of the following activities?
Working in her rose garden.
114
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse's instructions when he states he will:
Lose weight.
115
A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
Medication therapy.
116
When planning care for a client with viral hepatitis, the nurse should review labororatory reports for which of the following abnormal laboratory values?
Prolonged prothrombin time.
117
A nurse is administering oxytocin (Pitocin) to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's care plan?
strict monitoring of intake and output.
118
A 45-year-old client with colon cancer states, “I don’t want any treatment. I haven’t seen any family members in 25 years. I’m a loner. Besides, I’ll decide when and how I want to die.” In which order of priority from first to last should the nurse do the following?
* Ask the client about thoughts of suicide.
* Ask the client what methods of suicide are available.
* Express concern for the client's feelings and safety.
* Tell the client that the primary care provider will ask for a psychiatric consult.
119
The nurse is making a follow-up telephone call to a 52-year-old client with lung cancer. The client now has a low-grade fever (100.6° F [38.1° C]), nonproductive cough, and increasing fatigue. The client completed the radiation therapy to the mass in the right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. The nurse should advise the client to:
To contact the physician for an appointment today.
120
During the clinical breast examination, which of the following is a normal finding?
Long-term, bilateral nipple inversion.
121
Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which instruction?
Use sunscreen whenever going outside.
122
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
Continue the lithium and reassure the client that these temporary side effects will subside.
123
A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client?
Nitroprusside
124
The night nurse has completed a change-of-shift report. The day nurse making rounds notes that a postpartum client receiving magnesium sulfate has developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below ordered. In addition to adjusting the infusion rate and notifying the primary health care provider, which of the following actions by the day nurse is most important?
Complete an incident report.
125
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents:
Do you give the baby a bottle to take to bed?
126
A clinical nurse specialist developed clinical pathways for common orthopedic conditions. The interdisciplinary team uses these pathways to:
provide a care plan for caregivers to ensure continuity of care.
127
A dilatation and curettage (D&C;) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which of the following feelings?
Guilt.
128
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
The client receives a complete bed bath each morning.
129
A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?
When my moods fluctuate, I'll increase my dose of lithium.
130
A nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse (LPN). Which statements by the LPN indicate her understanding of HIV transmission? Select all that apply.
* "I'll wear a mask, gown, and gloves when splashing of body fluids is likely."
* "I'll wash my hands after client care."
131
A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply.
* "Use pressure-reduction devices."
* "Reposition every 1 to 2 hours."
* "Teach the family how to care for the wound."
* "Clean the area around the ulcer with mild soap."
132
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?
Report back to the nurse immediately if any client has an output less than 240 ml.
133
A nurse should determine a child's body surface area by using:
a nomogram.
134
A laboring client at –2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
Place gentle pressure upward on the fetal head.
135
A client in labor has an episiotomy. The nurse understands that the client is at risk for which complication?
Prolonged dyspareunia
136
When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which of the following? Select all that apply.
* Decreased muscle tone
* Decreased respirations
137
A client with schizophrenia tells a nurse preparing him for discharge that he has no home or family and has been living on the street. Which action is most appropriate?
Asking the physician to refer the client to social services for further evaluation
138
The nurse manager on a pediatric floor is reviewing national sentinel event alerts and preparing recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply.
* Utilize only oral syringes to administer oral medication.
* Limit the size of IV fluid bags that can be hung on small children.
* Reduce the available concentrations or dose strengths of high alert medications to the minimum.
139
The client has various sensory impairments associated with diabetic disease. The nurse determines that the client needs further instruction when he states which of the following?
I'll avoid kitchen activities.
140
What should the nurse teach the client to do to prevent stress incontinence? Select all that apply.
* Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises.
* Avoid dietary irritants (e.g., caffeine, alcoholic beverages).
141
During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, "I can't gain weight. I'm fat enough as it is. I'll be really disgusting if I get fatter." When responding to this client, which response by the nurse would be most therapeutic?
Use nonjudgmental and realistic comments.
142
During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal?
The baby's stools are bright yellow and soft.
143
The nurse is assessing a client who has a chronic mental illness. Which of the following are early signs of relapse? Select all that apply.
* Decrease in sleep and self-care.
* Increase in social isolation and withdrawal.
* More fears and suspiciousness.
144
Which of the following groups would benefit most from education regarding potential risk factors for melanoma?
Parents with children.
145
When caring for a client who's being treated for hyperthyroidism, the nurse should:
balance the client's periods of activity and rest.
146
The physician has determined that a primigravid client in active labor requires a cesarean delivery because of cephalopelvic disproportion. After the delivery of a male neonate, for which of the following should the nurse assess first?
Nasopharyngeal secretions.
147
A client has been placed on isoniazid (INH) as prophylactic treatment against tuberculosis. Which of the following instructions should the nurse plan to include in the client’s teaching plan about taking isoniazid?
The client should limit tyramine-rich foods in the diet.
148
A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy?
Inform the nurse director she's violating the client's right to privacy and ask her to return the chart.
149
A neonate is to receive an I.V. infusion of normal saline solution at 3 ml/hour. The nurse is setting the alarms on an I.V. infusion pump. How should the nurse set the alarms?
At 5% above and 5% below the keep-vein-open rate.
150
A 22-year-old client loses her fiancé in a drunk-driving accident. She complains of difficulty eating, sleeping, and working. Her reaction is considered:
a crisis caused by traumatic stress.
151
A mute client begins to express herself verbally on occasion. Which of the following nursing actions should be credited with helping a mute client express herself verbally?
Making open-ended statements followed with silence.
152
A 62-year-old client with a 29-pack per year history is admitted with a diagnosis of lung cancer. She reports having "no appetite" and exhibits symptoms of anorexia. The client is 5 feet, 8 inches tall and weighs 112 lb. The client is now scheduled for a left lung lobectomy. Which of the following increases the client's risk of developing postoperative pulmonary complications?
The client is 5 feet, 8 inches tall and weighs 112 lb.
153
A 6 month old is taken to the pediatrician, and the mother states that the child is not growing like other 6 month olds in families whom she knows. The birth weight of the child was 7 pounds 11 ounces, and the current weight is 11 pounds 2 ounces. The nurse would instruct the client that:
The child is underweight and needs a dietary assessment.
154
The nurse is assessing fetal position for a 32-year-old client in her eighth month of pregnancy. As shown below, the fetal position can be described as which of the following?
Left occipital transverse.
155
A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is:
4
156
A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response?
Notify the anesthesiologist.
157
A client is diagnosed with oligohydramnios during a clinic visit. Before the client gives birth, the nurse should notify the nurses working in the nursery about the diagnosis so they are aware of which complication that's commonly associated with oligohydramnios?
Renal malformations
158
A child, age 5, with an intelligence quotient (IQ) of 65 is admitted to the facility for evaluation. When planning care, the nurse should keep in mind that this child:
would have a diagnosis of mild mental retardation.
159
A 62-year-old woman thinks her husband's rehabilitation needs have been unmet by his employer after his diagnosis and treatment of colon cancer. The nurse should give her information about:
The Americans With Disabilities Act of 1990.
160
To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?
Decrease the carbohydrate content of meals.
161
While reviewing a client's chart, the nurse notices that the client has myasthenia gravis. Which statement about neuromuscular blocking agents is true for a client with this condition?
Pancuronium and succinylcholine both require cautious administration.
162
A client with the nursing diagnosis of Fear, related to being embarrassed in the presence of others, exhibits symptoms of social phobia. What should the goals be for this client? Select all that apply.
* Manage his fear in group situations.
* Verbalize feelings that occur in stressful situations.
* Develop a plan for responding to stressful situations.
163
The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates:
Urine retention.
164
A female client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting?
Denial
165
Following the formation of an ileal conduit, the nurse notes that the client’s urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data?
These findings are normal for a client with an ileal conduit.
166
A client is scheduled for urinary diversion surgery to treat bladder cancer. Before surgery, the health care team — consisting of a nurse, dietitian, social worker, enterostomal therapist, surgeon, client educator, and mental health worker — meets with the client. After the meeting, the client states, "My life won't ever be the same. What am I going to do?" Which health care team member should the nurse consult to help with the client's concerns?
Client educator
167
When monitoring a client recently admitted for treatment of cocaine addiction, a nurse notes sudden increases in the arterial blood pressure and heart rate. Which medication should the nurse prepare to administer?
Nifedipine (Procardia)
168
The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which of the following parameters is not necessary every 15 minutes during the first postoperative hour?
Urine output.
169
A client who's 3 months pregnant with her first child reports that she has had increasing morning sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal heart tones. The nurse should suspect which complication of pregnancy?
Gestational trophoblastic disease
170
Which nursing action is essential when providing continuous enteral feeding?
Elevating the head of the bed
171
A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because:
they contain high levels of phenylalanine.
172
Which change does a nurse demonstrate when she helps a young mother adjust to the birth of her child?
Situational
173
A client recruited to participate in a clinical trial to treat non-Hodgkin's lymphoma tells a nurse and physician that he's willing to start the trial, but doesn't know if adverse effects of the treatment will prevent him from completing it. To protect the ethical principle of autonomy, the nurse must tell the client:
that he may withdraw at any time.
174
A client with borderline personality disorder becomes angry when he is told that his psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse is most helpful in dealing with the client's anger?
You had to wait. Can we talk about how this is making you feel right now?
175
A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that:
it may be necessary to raise the head of this client's bed.
176
The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.
* Vitamin B6.
* Vitamin B12.
* Folate.
177
A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement?
Decreased hematuria
178
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.
179
Which of the following clients would be most appropriate for the nurse to assign to the nursing assistant for morning care?
An elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea.
180
When obtaining the nursing history of a client who has diabetes mellitus, the nurse should assess the client for which of the following early symptom of renal insufficiency?
Polyuria.
181
An 18 month old with a congenital heart defect is to receive digoxin (Lanoxin) twice a day. The nurse should instruct the parents about which of the following?
Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.
182
A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:
isolate the client's bed linens until the client is no longer infectious.
183
An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician orders a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client's well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for:
a history of diabetes mellitus.
184
A 4 year old with a history of urinary reflux returned from surgery for bilateral ureteral re-implants 2 days ago. Which assessment finding is most concerning?
Decreased oral intake.
185
A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100° F (37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the primary health care provider to order?
Intravenous penicillin (Penicil).
186
An 18-year-old client is seen in the emergency department following a fall from a horse. After vigorously cleaning a large, dirty laceration on his leg, a nurse closes and dresses the wound. The client has, in the past, received the full tetanus-toxoid immunization regimen, but tells the nurse he had his last shot when he was 11 years old. The nurse should:
plan on administering a dose of tetanus vaccine.
187
The nurse understands that the client who has epidural pain management postoperatively can ambulate because:
A low concentration of analgesia is used with the catheter.
188
Which of the following are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply.
* Medical record number.
* Name band.
189
Which of the following is a late symptom of polycythemia vera?
Pruritus.
190
A pregnant client is experiencing a thin, odorless, vaginal discharge. What should a nurse tell her to do to prevent vaginal infections?
Try wearing a panty liner and discarding it after every urination.
191
A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site?
Change the needle every 3 days.
192
A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which of the following should the nurse expect the primary health care provider to order?
Fresh-frozen platelets.
193
A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?
11 weeks' gestation
194
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?
Serum potassium level of 3 mEq/L
195
Which action should the nurse take first when admitting an 11-year-old child in sickle cell crisis?
Begin I.V. fluids after obtaining the child's history.
196
A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to:
walk from his room to the end of the hall and back before discharge.
197
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
Administering famotidine (Pepcid) as ordered.
198
The nurse is assessing an 80-year-old client who has scald burns on both hands and forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first?
Refer the client to a burn center.
199
A nurse is teaching a client how to administer oxytocin (Syntocinon) for lactation stimulation. The teaching has been successful if the client administers the drug:
sitting with her head vertical.
200
A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response?
Can you tell me why you want to take your child home now?
