All Clients Need (1001-1200) Flashcards
(200 cards)
1
Q
Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance?
A
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
2
Q
A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse should tell the client that:
A
a bowel-cleansing procedure will precede radioactive implantation.
3
Q
A primigravid client at 37 weeks’ gestation has been hospitalized for several days with severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
A
Call for immediate assistance in the client’s room.
4
Q
A client is entering the chemical dependency unit for treatment of alcohol dependency. Which of the client’s possessions should the nurse place in a locked area?
A
Antiseptic mouthwash.
5
Q
A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor, the nurse should expect to administer:
A
terbutaline (Brethine).
6
Q
A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.
A
- Instill isotonic eye drops, as necessary.
- Provide several small, well-balanced meals.
- Provide rest periods.
- Weigh the client daily.
7
Q
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?
A
Increased risk for urinary tract infections.
8
Q
The membranes of a 26-year-old primigravida at 40 weeks’ gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. Which of the following should the nurse do next?
A
Administer oxygen at 8 to 10 liters by mask.
9
Q
Ibuprofen (Motrin) is prescribed for a client with osteoarthritis. Which of the following instructions about ibuprofen should the nurse include in the client’s teaching plan?
A
Take with food or antacids.
10
Q
A nurse is frustrated by her inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. Her most professional response would be to:
A
discuss the situation with a more experienced peer.
11
Q
The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
A
Force fluids.
12
Q
On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next?
A
Anticipate that the physician will order laboratory tests and cultures.
13
Q
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client’s nose. What should the nurse do first?
A
Test the nasal drainage for glucose.
14
Q
At what age should a boy be taught how to do a monthly testicular self-examination?
A
12 years
15
Q
A client with muscle weakness and an abnormal gait is being evaluated for muscular dystrophy. Which test or finding confirms muscular dystrophy?
A
Muscle biopsy
16
Q
A 16-year-old unmarried primigravid client at 37 weeks’ gestation with severe preeclampsia is in early active labor. The client’s blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure?
A
Epigastric pain.
17
Q
A nurse is caring for a client with cystic fibrosis. With which members of the health care team is it most appropriate for her to collaborate? Select all that apply.
A
- Nutritional services
- Physical therapy
- Respiratory therapy
18
Q
In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client voices which of the following?
A
I get so angry at times that I have to have a couple of drinks before I sleep.
19
Q
A client in the second stage of labor is fully dilated. Which nursing action is appropriate for this stage of labor?
A
Assessing vital signs every 15 minutes
20
Q
The nurse is taking care of a client with Clostridium difficile. The nurse should do which of the following to prevent the spread of infection? Select all that apply.
A
- Wear a protective gown when in the client’s room.
- Wash hands with soap and water.
21
Q
The parents of a neonate with a cleft lip are shocked when they see their child for the first time. Which of the following nursing actions should the nurse include in the neonate’s plan of care to help the parents accept their newborn’s anomaly?
A
Showing them pictures of babies before and after corrective surgery.
22
Q
A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?
A
A client 4 days postoperative after mitral valve replacement
23
Q
A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action best identifies potential complications of this disease?
A
Instituting cardiac monitoring
24
Q
A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client’s room. The client becomes very agitated and declares, “The aliens have arrived!” Which actions are appropriate for the nurse to take? Select all that apply.
A
- Staying with the client until she receives further instructions
- Continuing to speak to the client in a reassuring tone
25
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
Seizures.
26
Which measurement should a nurse use to monitor the respiratory status of a client with pulmonary edema?
Arterial blood gas (ABG) analysis
27
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?
Metabolic alkalosis
28
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status?
Can you ride a tricycle?
29
A client commonly jumps when spoken to and reports feeling uneasy. The client says, “It’s as though something bad is going to happen.” In which order from first to last should the following nursing actions be done?
* Reduce environmental stimuli.
* Ask the client to deep breathe for 2 minutes.
* Discuss the client’s feelings in more depth.
* Teach problem solving strategies.
30
A client in the manic phase of bipolar disorder is admitted to the facility. Which agents are appropriate for this client?
Lithium (Lithobid) and valproic acid (Depakote)
31
A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to:
help the family prepare for the infant's imminent death.
32
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
Provide the client with oral hygiene.
33
Which of the following factors contribute to a risk for amputation in a client with peripheral vascular disease? Select all that apply.
* Uncontrolled diabetes mellitus for 15 year.
* A 20-pack-year history of cigarette smoking.
* A serum cholesterol concentration of 275 mg/dL.
34
A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?
Posterior tibial
35
The emergency department nurse has admitted an infant with bulging fontanels, "setting sun" eyes, and lethargy. Which of the following diagnostic procedures would be contraindicated in this infant?
Lumbar puncture.
36
The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first?
Obtain a culture specimen of the drainage.
37
Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching?
Fetal nutrients are provided by the amniotic fluid.
38
Which of the following would be true regarding medication reconciliation? Select all that apply.
* Medication reconciliation is a Joint Commission National Patient Safety Goal.
* Medication reconciliation is designed to obtain and communicate an accurate list of a client's home medications across the continuum of care.
* Medications are considered reconciled if a medication order exists that is therapeutically equivalent to the one prior to admission.
39
A nurse is caring for a 10 month old who weighs 8.0 kg and has been admitted for dehydration. The infant has vomited five times in the last 3 hours and has had no wet diapers in the last 8 hours. The nurse informs the primary healthcare provider. Which of the following orders should the nurse question?
Begin an IV line and administer a fluid bolus of Dextrose 35%.
40
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?
Transitional phase
41
A male neonate with a 3 X 5 cm sac in the lumbar region of his back is diagnosed with myelomeningocele. What should the nurse expect to find when inspecting this sac?
Spinal fluid, nerve tissue, and spinal bony defect.
42
After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of dextrose 5% in water infusing at 40 ml/hour, and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters does the nurse calculate as urine? Record your answer using a whole number. Do not use any commas.
1180
43
Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply.
* "I encourage you to eat small, frequent meals."
* "An adequate intake of protein is important to your health."
44
What is the approximate time that the blastocyst spends traveling to the uterus for implantation?
7 days
45
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
Increased urine output
46
A client with advanced stomach cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to order:
fluorouracil (5-fluorouracil, 5 FU [Fluoroplex]).
47
A 4-week-old infant admitted with the diagnosis of hypertrophic pyloric stenosis presents with a history of vomiting. The nurse should anticipate that the infant's vomitus would contain gastric contents and which of the following?
Mucus and streaks of blood.
48
The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate?
Every person is different. What works for one client may not always be effective for another.
49
Clonidine (Catapres) can be used to treat hypertension as well as:
opioid withdrawal.
50
The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
Improve the nurse-client relationship.
51
A home health nurse visits a client who's taking pilocarpine (Pilocar), a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.
52
A client who has asthma is taking albuterol (Ventolin) to treat bronchospasms. The nurse should assess the client for which of the following adverse effects that can occur as a result of taking this drug? Select all that apply.
* Headache.
* Nervousness.
* Nausea.
53
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
An acute bilateral ear infection.
54
A parent asks the nurse about the major causes of brain injury in children. What should the nurse include in the response as the most common causes? Select all that apply.
* Falls.
* Motor vehicle accidents.
* Bicycle accidents.
55
A nurse is preparing to discharge a child who has rheumatic fever. The nurse plans to teach the parents about which medication that will be used to prevent a recurrence of the disease?
Antibiotics
56
Following a boating accident, a client with multiple fractures is admitted to a semiprivate room in a progressive care unit. The client, who was piloting the boat, is unaware that his girlfriend's 9-year-old son was killed in the accident. The client's parents instruct the nurse to prohibit phone calls and to withhold information about the accident. During an assessment of the client, the nurse notices that the television is on and the news is starting. What should the nurse do?
Allow the client to view the television and deal with any questions as they come.
57
A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?
Opioids
58
A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she's been validated on obtaining fingerstick glucose readings. The nursing assistant says she didn't have the skill validated, but she's seen it done many times and knows she can do it. What should the nurse do?
Go with the nursing assistant into the client's room, and validate her ability to perform the procedure.
59
A client with osteoarthritis will undergo an arthrocentesis on a painful edematous knee. What should be included in the nursing plan of care? Select all that apply.
* Explain the procedure.
* Assess the site for bleeding.
* Offer pain medication.
60
The nurse is to wear personal protective equipment (PPE) to administer a chemotherapeutic agent to the client. The nurse should use which of the following guidelines for PPE use and care? Select all that apply.
* Understand the proper use and limitations of PPE.
* Use care in removing all items to reduce contamination.
* Discard the PPE in containers for contaminated waste.
61
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?
Keeping extraneous noise to a minimum.
62
As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond?
We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them.
63
Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemble those used for:
general anesthesia.
64
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
With two people, one at each side using a drawsheet, one person at the head, and one person at the feet.
65
A nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the American Nursing Association Code of Ethics. The nurse correctly explains that the code asks nurses to demonstrate which of the following? (Select all that apply.)
* Be responsible and accountable for individual practice.
* Maintain integrity and shape social policy.
* Develop, maintain, and improve health care environments.
* Increase professional competence and personal growth.
66
The definition of a nihilistic delusion is:
false belief that one is dead or that a calamity is about to occur.
67
Umbilical cord prolapse necessitated cesarean birth of a preterm, low-birth-weight neonate. Immediately after birth, the neonate is limp, gasping for air, unresponsive to stimulation, and has blue discoloration of the face, lips, and torso. Which intervention should the nursery nurse perform first?
Determine unresponsiveness and assess the need for resuscitation.
68
A physician has ordered hydrochlorothiazide (HydroDIURIL) for a client diagnosed with Ménière's disease. Which instruction should the nurse include in the teaching session?
Increase your intake of bananas, tomatoes, and oranges.
69
The client is to be discharged from the hospital after a safe, medically supervised withdrawal from alcohol. Which of the following outcomes indicate client readiness for an outpatient alcohol treatment program? Select all that apply.
* The client verbalizes the damaging effects of alcohol on his body.
* The client plans to attend Alcoholics Anonymous meetings.
* The client takes naltrexone (ReVia) daily.
70
The nurse discusses the eating habits of school-age children with their parents, explaining that these habits are most influenced by:
Examples provided by parents at mealtimes.
71
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that:
No special preparation is required for the examination.
72
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD): pH 7.35; PC02 62; PO2 70; HCO3-- 34. The nurse should:
Assess the vital signs.
73
A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the:
Upper gingival mucosa in the space between the upper gums and lip.
74
A nurse is caring for a terminally ill client. Place the five stages of death and dying described by Elisabeth Kubler-Ross in the order in which they occur. Use all options.
* Denial and isolation
* Anger
* Bargaining
* Depression
* Acceptance
75
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
10 seconds.
76
A 4-month-old infant has been carried into the emergency department after falling off his parents' bed and hitting his head on the floor. What should the nurse do next?
Move the family to an area where an assessment can be completed and call for a physician.
77
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
Initiating IV sedation.
78
Thirty people are injured in a train derailment. Which client should be transported to the hospital first?
A 25-year-old with a sucking chest wound.
79
When teaching a client about levodopa-carbidopa (Sinemet) therapy for Parkinson's disease, a nurse should include which instruction?
Be aware that your urine may appear darker than usual.
80
A staff member says she's really busy and asks the charge nurse to double-check a dose of insulin she has drawn up. The nurse holds up a bottle of Lente insulin, but the charge nurse notices a bottle of Lantus insulin on the medication cart. This nurse has made multiple medication errors and the charge nurse is concerned that she isn't safe. What should the charge nurse do?
Tell the nurse that she'd like to start at the beginning to be on the safe side.
81
A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first?
Apply an ice pack for 20 minutes.
82
Which of the following nursing strategies would be effective in managing a client who has Alzheimer's disease and wanders?
Involve the client in activities that promote walking.
83
A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis?
Pulmonary hypertension
84
Which of the following statements best explains why the nurse should acknowledge differences between his or her culture and the client’s culture?
The nurse may hold values that could influence the care of the client.
85
A client recovering from a closed head injury is restless and agitated. He still has a central venous catheter in place for antibiotic therapy. The nurse doesn't want to sedate the client, but she needs to protect the catheter and other less-restrictive measures have failed. Which method of restraint is best for this client?
Mitt restraints applied to both hands
86
A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the client's primary health care provider?
The transfer of the client to a medical unit.
87
A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care?
The client entered a clinical trial through the National Cancer Institute.
88
A physician orders home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use?
Home health nurse
89
A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?
Applying knee splints
90
An African-American woman had experienced severe palpitations, weakness, and shortness of breath after taking bacitracin (Bactrim). As a part of the discharge planning, the nurse should evaluate the client's knowledge about:
Congenital enzyme deficiency.
91
An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect her rights during the physical examination?
Have a female health care worker present.
92
A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options.
* Trust versus mistrust
* Autonomy versus shame and doubt
* Initiative versus guilt
* Industry versus inferiority
* Identity versus role confusion
93
During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?
Introducing new issues to the client
94
A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume?
Serum osmolality will be within normal limits.
95
An adolescent with chest pain goes to the school nurse. The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next?
Obtain a peak flow reading.
96
For the client experiencing alcohol withdrawal delirium, which of the following primary care provider orders should the nurse question?
chlorpromazine (Thorazine), 100 mg P.O. every 4 hours p.r.n.
97
A nurse is working with a client with bulimia. Which of the following goals should be included in the care plan? Select all that apply.
* The client will maintain normal weight.
* The client will comply with medication therapy.
* The client will achieve a positive self-concept.
* The client will acknowledge the disorder.
98
A mother is concerned about the amount of snacking her teenage boy is doing. She is concerned that this behavior could lead to obesity. Which of the following is an appropriate percentage of the daily diet to be obtained from snacks?
25%.
99
A nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:
tell the client specifically and concisely what needs to be done.
100
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician prescriptions include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 ml/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should first:
Increase the oxygen flow rate from 2 to 4 L/minute.
101
Which of the following is an early symptom of glaucoma?
Impaired peripheral vision.
102
A nurse prepares a client who's 28 weeks pregnant for a nonstress test (NST). Which intervention is most likely to stimulate fetal movements during this test?
Having the client drink orange juice
103
A newborn with a cleft palate at one hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?
Encourage the mother to breast-feed.
104
Which drug delivery system most effectively reduces the likelihood of medication errors?
Automated
105
A 14-month-old child with acquired immunodeficiency syndrome (AIDS) is admitted to the facility with an infection. When developing a care plan, the nurse must keep in mind that AIDS in children commonly is associated with:
developmental delays.
106
Assessment of a client progressing through labor reveals several findings. Order the findings in the sequence in which they most likely occurred. Use all options.
* Strong Braxton Hicks contractions
* Mild contractions lasting 20 to 40 seconds • Cervical dilation of 7 cm
* 100% cervical effacement
* Uncontrollable urge to push
107
An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse's priority should be the potential for:
aspiration.
108
A physician orders an I.M. injection for a client. Which factor at the I.M. injection site may affect the absorption rate of a drug?
Blood flow to the injection site
109
A physician admits a client with a history of I.V. drug abuse to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has:
Osler's nodes and splinter hemorrhages.
110
When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of:
fresh fruits.
111
The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the Emergency Department. The nurse should assess the child for:
Hypoxia.
112
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
Using a Venturi mask to deliver oxygen as ordered
113
When performing a physical examination on an anxious client, a nurse should expect to find which effect produced by the parasympathetic nervous system?
Hyperactive bowel sounds
114
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks little English. The client’s mother asks the nurse if she can bring her daughter some “special foods from home.” The nurse responds, based on the understanding about which of the following?
The mother can bring the daughter any foods that she desires.
115
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
5 to 20 minutes.
116
A client with anorexia nervosa tells a nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to promote the client's receptivity to treatment?
Provide objective data and feedback regarding the client's weight and attractiveness.
117
During the client-teaching session, which instruction should the nurse give to a client receiving alprazolam (Xanax)?
Inform the physician if you become pregnant or intend to do so.
118
Which use of restraints in a school-age child should the nurse question?
To substitute for observation
119
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
Use a printed checklist with information individualized for the client.
120
A viable male neonate delivered to a 28-year-old multiparous client by cesarean delivery because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?
Neonate delivered preterm.
121
The nurse is preparing a client for a paracentesis. The nurse should:
Have the client void immediately before the procedure.
122
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Call the physician immediately.
123
The nurse on an orthopedic unit is instituting a falls prevention program. Which of the following personnel should be involved in the program? Select all that apply.
* Registered nurses.
* Physicians.
* Unlicensed personnel.
* Housekeeping services.
* Family members.
* Client.
124
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
125
Which of the following compensatory actions by the body would occur if a client were in respiratory acidosis?
Retention of HCO3- by the kidneys.
126
A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should:
Administer lorazepam (Ativan).
127
A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively?
Help the client assume a more comfortable position.
128
A nurse is caring for a client who has had extensive abdominal surgery and is in critical condition. The nurse notes that the complete blood count shows an 8 g/dl hemoglobin and a 30% hematocrit. Dextrose 5% in half-normal saline solution is infusing through a triple-lumen central catheter at 125 ml/hour. The physician orders include: Gentamicin (Garamycin) 80 mg I.V. piggyback in 50 ml D5W over 30 minutes. Ranitidine (Zantac) 50 mg I.V. in 50 ml D5W piggyback over 30 minutes. One unit of 250 ml of packed RBCs over 3 hours. Flush the nasogastric tube with 30 ml normal saline every 2 hours. How many milliliters should the nurse document as the intake for the 8-hour shift? Record your answer using a whole number.
1470
129
Which of the following actions is most appropriate when dealing with a client who is expressing anger verbally, is pacing, and is irritable?
Conveying empathy and encouraging ventilation.
130
When explaining the plan of care to the parents of an infant with an undescended testis, the nurse should tell the parents about which of the following as a nonsurgical treatment method?
A trial of human chorionic gonadotrophic hormone.
131
A client returns from a myelogram, for which an iodized oil (Pantopaque) was used. Which of the following nursing measures should be included in the care of this client?
Assessment of lower extremity movement and sensation.
132
A mother asks the nurse when she should wean her 4-month-old infant from breast-feeding and begin using a cup. What should the nurse explain as the best indication of the infant's readiness to be weaned?
Decreased interest in nursing.
133
The client with gastroesophageal reflux disease (GERD) complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?
Aspiration of gastric contents.
134
A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never been this sick before. Which of the following should be the most helpful statement to make to the daughter?
The doctor will order tests to find out what is causing her condition.
135
The nurse is assessing a teenage girl (see figure). The nurse should describe the girl shown in the figure as having:
Lordosis.
136
A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. He requests that his evaluation and counseling records be e-mailed to his Human Resources representative. How should the nurse respond?
It's best not to send your records electronically because doing so might jeopardize your right to privacy.
137
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?
Increase your fluid intake to 2 to 3 L per day.
138
When planning the care for a client diagnosed with hepatitis A, which of the following nursing interventions should the nurse include? Select all that apply.
* Providing relief from nausea and vomiting.
* Planning frequent rest periods.
* Encouraging multiple small meals daily.
139
When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse uses:
applied anatomy.
140
A client has been diagnosed with hepatitis A. Which of the following is most commonly used for prophylactic treatment of people exposed to hepatitis A?
Immune serum globulin.
141
A client returns to an intensive care unit after coronary artery bypass graft surgery, which was complicated by prolonged cardiopulmonary bypass and hypotension. After 3 hours in the unit, the client's condition stabilizes. However, the urine output has decreased despite adequate filling pressures. The nurse expects the physician to add which drug, at which flow rate, to the client's regimen?
Dopamine (Intropin), 3 mcg/kg/minute
142
A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client?
Rape-trauma syndrome
143
Throughout the first 3 weeks after a client has had a C7 spinal cord injury, the nurse should particularly assess the client for which of the following? Select all that apply.
* Tachycardia.
* Rapid respirations.
* Bladder incontinence.
144
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which situation?
This is a normal adverse effect of phototherapy.
145
The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply.
* Clients must eat within view of a staff member.
* Clients are not told their weight and cannot see their weight while being weighed.
* Clients must rest within view of a staff member and not go o the bathroom for one half hour to an hour after eating.
146
When assessing a client who has just given birth, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do?
Have the client void.
147
A nurse on the labor-and-delivery unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client delivered the neonate by vaginal delivery. Which of the following information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit?
Firm fundus when gentle massage is used.
148
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
* Change the feeding apparatus every 24 hours.
* Slow the administration rate.
* Use a diluted formula, gradually increasing the volume and concentration.
* Anticipate changing to a lactose-free formula.
149
A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate?
Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
150
A child, age 5, is diagnosed with chronic renal failure. When teaching the parents about diet therapy, the nurse should instruct them to restrict which foods from the child's diet?
Meats
151
Which laboratory study is most relevant to treating a client who has sustained a pelvic fracture?
Type and crossmatch
152
A client who is 14 weeks pregnant states, "Ever since I've been pregnant, I've had a hard time moving my bowels." Increased levels of what hormone are responsible for this common discomfort of pregnancy?
Progesterone
153
The physician has prescribed 5 mg Coumadin (warfarin) orally for a hospitalized client. In planning care for this client, the nurse should verify which of the following services have been contacted? Select all that apply.
* Dietary
* Laboratory.
* Pharmacy.
154
A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects?
If I eat too many fruits, I'll get constipated.
155
A neonate delivered at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate?
Use of humidity in the incubator.
156
A client receives midazolam, 2 mg I.V. as sedation before bronchoscopy. Five minutes after he receives the drug, his respiratory rate drops to 4 breaths/minute. Which agent should the nurse administer to reverse the effects of midazolam?
Flumazenil (Romazicon)
157
After teaching a client about lorazepam (Ativan), which of the following client statements indicates the need for further teaching? Select all that apply.
I can stop taking Ativan immediately if I need to.
158
In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which of the following areas should the nurse try first if an appropriate vein is found?
Back of the hand.
159
The expected outcome for using thiamine for a client being treated for an alcohol addiction is to:
Prevent the development of Wernicke's encephalopathy.
160
On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?
Hypotension
161
Which of the following is the highest risk for a child with leukemia whose laboratory values are as follows: WBC 6,500 mm3, platelet count 40,000 ul, and HCT 41.2%?
Bleeding
162
While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client’s rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching?
“I should lie on my back as much as possible to relieve the pain.”
163
During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response?
When people are under stress, they may see things or hear things that others don't. Is that what just happened?
164
When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which of the following foods? Select all that apply.
* Cooked dry beans.
* Peanut butter.
* Yogurt
165
When developing the plan of care for a client diagnosed with a personality disorder, the nurse plans to assist the client primarily with which of the following?
Specific dysfunctional behaviors.
166
The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which of the following points in the teaching plan?
The infant's diet can be changed from formula to whole milk when the infant is 12 months old.
167
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?
Nonrebreather mask
168
A 9-month-old infant whose parents have emigrated from Mexico presents in the clinic with severe dehydration from vomiting. The infant was seen in the clinic just 3 days ago for a well-child visit, but now the family seems very distrustful of the health care team. The nurse should ask the parents:
Did anything concern you about your last visit?
169
A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use first?
Reassure the client that her feelings are typical reactions to serious trauma.
170
A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of:
how well the neonate tolerated labor.
171
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following?
Blindness secondary to gonorrhea.
172
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
The rehabilitation plan will be guided by it.
173
Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences?
Air-fluidized surface
174
The nurse is preparing to start an intravenous infusion and has raised the head of the client's bed. After the nurse applies gloves to insert an I.V. catheter, the client begins to rub her eyes and wipe away nasal drainage. Which of the following should the nurse do first?
Remove the catheter and assess the client's vital signs.
175
A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session?
I will call my physician if I notice redness, warmth, and pain in my breasts.
176
A client is in the advanced stages of osteoarthritis. Which of the following best describes the pain that occurs in the advanced stage of the disease?
Pain occurs with minimal activity.
177
A child brought to the hospital with ketoacidosis is to receive regular insulin via an I.V. infusion. Which of the following I.V. solutions should the nurse expect the primary care provider to order initially?
0.9% saline.
178
A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
Assess client's ability to stand and bear weight before going to the bathroom.
179
After uncomplicated abdominal surgery, which of the following would be most appropriate when determining if an alert school-aged child is ready to drink oral fluids?
Auscultate the child's abdomen for bowel sounds.
180
A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is ordered. The nurse knows that morphine is given because it:
lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand.
181
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
maintain the client on complete bed rest with bathroom privileges only.
182
A client's breathing stops after receiving the wrong medication. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next?
Document the incident in the nurses' notes.
183
A depressed client tells a nurse, "I want to die. Life just isn't worth living." Which response by the nurse is most appropriate?
This must be a very difficult time for you.
184
A preadolescent child is suspected of being sexually abused because he demonstrates the self-destructive behaviors of self-mutilation and attempted suicide. Which common behavior should the nurse also expect to assess?
Truancy and running away.
185
A child, age 5, takes amoxicillin (Amoxil) orally three times per day to treat otitis media. For the most accurate calculation of a safe dosage, the nurse should use:
the child's body surface area.
186
A nurse should tell new mothers who are breast-feeding that breast milk is produced when:
the placenta is delivered, causing the secretion of prolactin.
187
The nurse is developing a care plan with an older adult with hypertension and is instructing the client that hypertension can be a "silent killer." The nurse should instruct the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
Cerebrovascular accidents (CVAs).
188
A nurse is preparing to help a client with weakness in his right leg move from his bed to a chair. Where should the nurse place the chair?
Parallel to the bed on the right side
189
After teaching the parents of a preschooler who has undergone a tonsillectomy and adenoidectomy about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching?
Cream of chicken soup and orange sherbet.
190
A charge nurse on the orthopedic unit functions to promote teamwork and to help the unit run smoothly. Which action should the charge nurse reconsider in order to promote teamwork?
Assisting the nurse to schedule Doppler ultrasonography for a client without discussing it with the physical therapist
191
The client is to receive 200 ml of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 ml of gastric residual. The nurse should:
Readminister the residual to the client and continue with the feeding.
192
Twenty-four hours after delivery, the nurse documents that involution is progressing normally after palpating the client's fundus at which of the following locations?
Slightly below the level of the umbilicus.
193
After the nurse has administered droperidol (Inapsine), care is taken to move the client slowly based on the knowledge of droperidol’s effect on the:
Cardiovascular system.
194
A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?
Decreased body temperature.
195
A preterm neonate is having frequent blood draws for laboratory specimens. The nurse should document the:
Amount of blood drawn for each specimen.
196
The nurse is caring for a client who will have a bilateral orchiectomy. The client asks what is involved with this procedure. The nurse's most appropriate response would be? "The surgery:
Results in reduction of the major circulating androgen, testosterone."
197
Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?
The client's feeling of grief is a normal reaction.
198
Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which of the following?
Allow the 5-year-old undivided attention several times a day.
199
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?
Increased pulmonary artery diastolic pressure
200
An adolescent with ulcerative colitis who is taking corticosteroids is at risk for which complication?
Delayed sexual maturation
