Med Surg Advanced Flashcards
(293 cards)
1
Q
A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?
a. Urticaria
b. Lymphedema
c. Headaches
d. Mouth sores
A
b. Lymphedema
2
Q
A nurse is preparing to administer lactated Ringer’s via continuous IV infusion at 200 mL/hr. The IV tubing has a drip factor of 10/drops/mL. How many gtts/min should the nurse set the IV pump to administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
A
33
3
Q
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
a. “I should lie down when I take this medication.”
b. “I can keep my medication for 1 year before replacing it.”
c. “I should discontinue this medication if I develop a headache.”
d. “I can take up to five tablets in 15 minutes before seeking medical
attention. ”
A
a. “I should lie down when I take this medication.”
4
Q
A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. “You should use an incentive spirometer every 8 hours.”
b. “You can cross your legs at the ankles when sitting down.”
c. “Clean the incision daily with hydrogen peroxide.”
d. “Install a raised toilet seat in your bathroom.”
A
d. “Install a raised toilet seat in your bathroom.”
5
Q
A nurse is planning care for a client following a cardiac catherization. Which of the following actions should the nurse take?
a. Limit the client’s fluid intake to 1 L per day.
b. Change the client’s dressing every 8 hr.
c. Keep the client on bed rest for 24 hr.
d. Maintain he client’s affected extremity in extension.
A
d. Maintain he client’s affected extremity in extension.
6
Q
A nurse is caring for a client who has a lower extremity fracture and prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us.”
b. “I feel bad that I have to ask my partner to keep the house clean.”
c. “These crutches will make it impossible to care for my child.”
d. “It’s going to be difficult to tell my parents I can’t take them to their appointments anymore.”
A
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us.”
7
Q
A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
a. “Wash your perineal area two times each day with antimicrobial soap.”
b. “Change the water in your drinking glass every 4 hours.”
c. “Change your pet’s litter box daily.”
d. “Wash your toothbrush in the dishwasher once each month.”
A
a. “Wash your perineal area two times each day with antimicrobial soap.”
8
Q
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications?
a. Nitroprusside
b. Epinephrine
c. Furosemide
d. Desmopressin
A
d. Desmopressin
9
Q
A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate?
a. “Sucking on a lozenge may reduce the frequency of your cough.”
b. “Increasing your daily fluid intake may eliminate your cough.”
c. “Your cough may require that you stop or change your medication.”
d. “Your cough should go away in time.”
A
c. “Your cough may require that you stop or change your medication.”
10
Q
A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud’s?
a. Eating a strict vegetarian diet
b. Taking amlodipine for hypertension
c. Using a nicotine transdermal patch
d. A history of herpes zoster
A
c. Using a nicotine transdermal patch
11
Q
A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first?
a. Clamp the catheter.
b. Turn the client to his left side.
c. Perform an ECG.
d. Obtain ABG values.
A
a. Clamp the catheter.
12
Q
A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care?
a. Support bony prominences with pillows.
b. Turn and reposition the client every 4 hr.
c. Massage the reddened areas three times daily.
d. Apply an occlusive dressing.
A
a. Support bony prominences with pillows.
13
Q
A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques.
b. List strategies for family coping when dealing with possible role changes.
c. Give the client information about the local National Multiple Sclerosis Society.
d. Review the use of adaptive grooming devices to promote client independence.
A
b. List strategies for family coping when dealing with possible role changes.
14
Q
A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? (Click the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
a. Obtain a sputum sample for culture.
b. Administer ondansetron.
c. Initiate airborne precautions.
d. Prepare the client for a chest x-ray
A
c. Initiate airborne precautions.
15
Q
A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client risk?
a. Diet high in fiber
b. History of Crohn’s disease
c. Age 46 years
d. BMI of 24
A
b. History of Crohn’s disease
16
Q
A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, “I’m not sure want to have a mastectomy.” Which of the following statements should the nurse make?
a. “I can give you additional information about the procedure.”
b. “You will be cancer-free if you have the procedure.”
c. “You should get a second opinion regarding the procedure.”
d. “I can give you a list of other people who had the same procedure.”
A
a. “I can give you additional information about the procedure.”
17
Q
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
a. Remain with the client for the first 15 to 30 min of the infusion.
b. Verify blood compatibility with another nurse.
c. Obtain the unit of packed RBCs from blood bank.
d. Obtain venous access using a 19-gauge needle.
e. Initiate transfusion of the unit of packed RBCs.
A
D,C,B,E,A
18
Q
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will have to wait 2 months before additional saline can be added to my breast expander.”
b. “I will perform strength-building arm exercises using a 15-pound weight.”
c. “I should expect less than 25 mL of secretions per day in the drainage devices.”
d. “I will keep my left arm flexed at the elbow as much as possible.”
A
c. “I should expect less than 25 mL of secretions per day in the drainage devices.”
19
Q
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client?
a. 2
b. 5
c. 13
d. 10
A
b. 5
20
Q
A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake 2 grams per day. Which of the following statements by the client indicates an understanding of the teaching?
a. “I can season my foods with garlic and onion salts.”
b. “I can drink vegetable juice with a meal.”
c. “I can have a frozen fruit juice bar for dessert.”
d. “I can have mayonnaise on my sandwiches.”
A
c. “I can have a frozen fruit juice bar for dessert.”
21
Q
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?
a. Collect information about the irritant that caused the injury.
b. Place a strip of pH paper onto the cul-de-sac of the affected eye.
c. Administer proparacaine eyedrops into the affected eye.
d. Instill 0.9% sodium chloride solution into the affected eye
A
d. Instill 0.9% sodium chloride solution into the affected eye
22
Q
A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
a. SaO2 92%
b. Stridor
c. Rhonchi
d. Sore throat
A
b. Stridor
23
Q
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
a. Decreased serum amylase
b. Elevated blood glucose
c. Elevated serum calcium
d. Decreased erythrocyte sedimentation rate
A
b. Elevated blood glucose
24
Q
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
a. Hypothermia
b. Urine specific gravity 1.001
c. BUN 15
d. Elevated blood pressure
A
b. Urine specific gravity 1.001
25
A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
a. Initiate a continuous IV heparin infusion.
b. Position the client on the left side.
c. Measure vital signs every 4 hr.
d. Instruct the client to massage the lower extremities.
a. Initiate a continuous IV heparin infusion.
26
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
a. Limit alcohol intake to one drink per day.
b. Limit fluids to 1.5 L per day.
c. Avoid extremely hot or cold temperatures.
d. Avoid getting a flu vaccination.
c. Avoid extremely hot or cold temperatures.
27
A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first?
a. Insert a large-bore IV catheter.
b. Obtain a blood specimen for type and crossmatch.
c. Administer IV therapy.
d. Monitor urine output.
a. Insert a large-bore IV catheter.
28
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulations of the graft?
a. Normotensive blood pressure
b. Dilated appearance of the graft
c. Absence of a bruit
d. Palpable thrill
d. Palpable thrill
29
A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia?
a. Muscle weakness
b. Oliguria
c. Hypertension
d. Positive Chvostek’s sign
a. Muscle weakness
30
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
a. Initiate a continuous IV insulin infusion.
b. Begin bicarbonate continuous IV infusion.
c. Administer 0.9% sodium chloride.
d. Check potassium levels.
c. Administer 0.9% sodium chloride.
31
A nurse is providing discharge teaching to a client who has ileostomy. Which of the following client statements indicates and understanding of the teaching?
a. “I will take a laxative when I’m constipated.”
b. “I will empty my bag when it is full.”
c. “I will expect my stools to be loose.”
d. “I will eat a high-fiber diet.”
c. “I will expect my stools to be loose.”
32
A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take?
a. Decrease the rate of infusion to last until the new bag is available.
b. Switch the infusion to a 10% dextrose solution.
c. Start an infusion of 0.45% sodium chloride solution.
d. Discontinue the infusion and flush the line.
b. Switch the infusion to a 10% dextrose solution.
33
A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances?
a. Hypocalcemia
b. Hypermagnesemia
c. Hypernatremia
d. Hypokalemia
a. Hypocalcemia
34
A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?
a. Command the dog to sit while talking with the client.
b. Consult the client before approaching the dog.
c. Pet the dog briefly to demonstrate acceptance.
d. Offer the dog a bowl of water to demonstrate caring.
b. Consult the client before approaching the dog.
35
A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
a. “I should take my daily aspirin on an empty stomach.”
b. “I should lie down before taking a dose of isosorbide dinitrate.”
c. “I should withhold my metoprolol if my heart rate is above 100 beats per minute.”
d. “I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses.”
b. “I should lie down before taking a dose of isosorbide dinitrate.”
36
A nurse in the postanesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4-in) area if blood on the postoperative dressing. Which of the following actions should the nurse take?
a. Loosen the dressing.
b. Circle the drainage.
c. Apply a new dressing.
d. Apply pressure.
d. Apply pressure.
37
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?
a. Maintain the client in supine position.
b. Empty water from the ventilator tubing daily.
c. Perform oral care every 2 hr.
d. Suction the client’s airway every 4 hr.
c. Perform oral care every 2 hr.
38
A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?
a. Provide a diet of fresh fruits and vegetables for the client.
b. Limit visitation time for the client’s children to 40 min per day.
c. Clean the equipment in the client’s room once per week.
d. Apply new gloves when alternating between wound care sites.
d. Apply new gloves when alternating between wound care sites.
39
A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following effects occurs?
a. Jaundice
b. Polyuria
c. Weight gain
d. Hair loss
a. Jaundice
40
A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?
a. Place a plate guard on the client’s meal tray.
b. Provide the client with a short-handed reacher.
c. Position the bedside table on the client’s left side.
d. Remind the client to use a cane on his left side while ambulating.
a. Place a plate guard on the client’s meal tray.
41
A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?
a. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal.
b. Point the tip of the syringe toward the top of the ear canal.
c. Use cool fluid for irrigation.
d. Tilt the client’s head 45o.
b. Point the tip of the syringe toward the top of the ear canal.
42
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
a. Sertraline
b. Methylprednisolone
c. Ondansetron
d. Diphenhydramine
c. Ondansetron
43
A nurse is preparing to discharge a client who has a halo device and is reviewing new prescription from the provider. The nurse should clarify which of the following prescriptions with the provider?
a. Take tub baths instead of showers.
b. May place a small pillow under the head when sleeping.
c. Increase intake of fiber-rich foods.
d. May operate a motor vehicle when no longer taking analgesics.
d. May operate a motor vehicle when no longer taking analgesics.
44
A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?
a. “Your provider will discontinue your medications after 3 months of therapy.”
b. “You can drink alcohol after the first 6 weeks of treatment.”
c. “You should wear an N95 respirator mask when you are at home.”
d. “You will need to return in 2 weeks to provide a sputum specimen.”
d. “You will need to return in 2 weeks to provide a sputum specimen.”
45
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
a. Bradycardia
b. Frothy sputum
c. Jugular vein distention
d. Flushed skin
b. Frothy sputum
46
A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan?
a. Place a large pillow under the client’s knees when resting.
b. Apply an ice pack directly to the client’s knees.
c. Administer acetaminophen for pain management.
d. Avoid using a topical salicylate cream.
c. Administer acetaminophen for pain management.
47
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?
a. Increase the client’s fluid intake.
b. Administer PRN pain medication.
c. Reposition the client in bed.
d. Check the client’s urine output.
d. Check the client’s urine output.
48
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which oof the following statements by the client indicates an understanding of the teaching?
a. “I use my heating pad on a low setting to keep my feet warm.”
b. “I rest in my recliner with my feet elevated for about an hour every afternoon."
c. “I soak my feet in hot water before trimming my toenails.”
d. “I apply a lubricating lotion to the cracked areas on the soles of my
feet every morning.”
b. “I rest in my recliner with my feet elevated for about an hour every afternoon."
49
A nurse in a provider’s office is teaching a client about the self- management of GERD. Which of the following instructions should the nurse include?
a. “Lie down for 30 minutes after each meal.”
b. “Eat a light meal 1 hour before bedtime.”
c. “Sleep with the head of your bed elevated 6 inches.”
d. “Increase your caloric intake by 250 calories per day.”
c. “Sleep with the head of your bed elevated 6 inches.”
50
A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. High-pitched sound on inspiration
b. Hypoactive bowel sounds
c. Loose tracheal secretions
d. Client report of pain at the incision site
a. High-pitched sound on inspiration
51
A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?
a. “The elastic bandage will prevent a postoperative wound infection.”
b. “The elastic bandage will prevent excessive edema.”
c. “The elastic bandage will keep you from seeing the surgical site.”
d. “The elastic bandage will keep the sutures from loosening.”
b. “The elastic bandage will prevent excessive edema.”
52
A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
a. Examine the surgical incision for drainage.
b. Palpate pulses distal to the graft donor site.
c. Measure the client’s core body temperature.
d. Auscultate breath sounds.
b. Palpate pulses distal to the graft donor site.
53
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
a. “You will need three follow-up blood tests within a 24-month period.”
b. “You will need to be monitored for 15 minutes after receiving each medication dose."
c. “You will need cryotherapy for 1 to 2 weeks.”
d. “You will need to take an antiviral medication 6 months.”
b. “You will need to be monitored for 15 minutes after receiving each medication dose."
54
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High-Fowler’s
d. Side-lying
b. Feet elevated
55
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
a. Dark red granulation tissue
b. Light yellow exudate
c. Dry brown eschar
d. Wound tissue firm to palpation
a. Dark red granulation tissue
56
A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
a. “I’ll insert the obturator after cleaning my stoma.”
b. “I’ll cleanse the cannula with half-strength hydrogen peroxide.”
c. “I’ll remove the soiled tracheostomy ties prior to cleaning my stoma.”
d. “I’ll cut a slit in a clean gauze pad to use as stoma dressing.”
c. “I’ll remove the soiled tracheostomy ties prior to cleaning my stoma.”
57
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
a. Sodium 136 mEq/L
b. Creatinine 0.8 mg/dL
c. Potassium 3.2 mEq/L
d. BUN 18 mg/dL
c. Potassium 3.2 mEq/L
58
A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?
a. Bilateral pupil diameter changes from 4 to 2 mm
b. Pulse pressure changes from 30 to 20 mm Hg
c. WBC count changes from 9,000 to 16,000/mm3
d. Glasgow Coma Scale score changes from 14 to 9
d. Glasgow Coma Scale score changes from 14 to 9
59
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
a. “I’ve been having problems with bladder control.”
b. “I have a hard time with brushing my hair.”
c. “I would rather be in a wheelchair than use a walker to get around.”
d. “I have difficulty swallowing food.”
b. “I have a hard time with brushing my hair.”
60
A nurse is providing discharge teaching to a client who will be self- administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
a. “You can discard needles in an empty bleach bottle with a lid.”
b. “Remove the needle from the syringe before you place it in the trash.”
c. “Secure the cap tightly over the needle before you discard it.”
d. “Place your storage container in a recycle bin when it is full.”
a. “You can discard needles in an empty bleach bottle with a lid.”
61
A nurse is assessing a client who has an arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access?
a. Dilated appearance of the AV site
b. 2+ left radial pulse
c. Absence of a bruit
d. Presence of a palpable thrill
c. Absence of a bruit
62
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
a. Familiarize themselves with commonly use signed language.
b. Obtain a board that uses colored pictures as communication.
c. Request an interpreter during the initial assessment.
d. Ask a family member to be present during the admission.
c. Request an interpreter during the initial assessment.
63
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
a. Position the mouthpiece 2.5 cm (1 in) from the mouth.
b. Exhale slowly through pursed lips.
c. Hold breaths about 3 to 5 seconds before exhaling.
d. Place hands on the upper abdomen during inhalation.
c. Hold breaths about 3 to 5 seconds before exhaling.
64
A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse take?
a. Assess the client’s neurological status every 8 hr.
b. Log roll the client every 4 hr.
c. Provide the client with a low-fiber diet.
d. Monitor urine output hourly.
d. Monitor urine output hourly.
65
A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?
a. Change the dressing every 24 hr.
b. Cleanse the site with povidone-iodine.
c. Use clean technique when changing the dressing
d. Flush the catheter using a 10-mL syringe.
d. Flush the catheter using a 10-mL syringe.
66
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?
a. Check the color of the client’s skin.
b. Remove all of the client’s clothing.
c. Administer an opioid analgesic.
d. Prepare the client for peritoneal lavage.
b. Remove all of the client’s clothing.
67
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
a. Inform the client they might experience a low-grade fever.
b. Provide the client with sips of water.
c. Check the client’s gag reflex.
d. Instruct the client to report bleeding.
c. Check the client’s gag reflex.
68
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
a. “Use peroxide to clean the mouthpiece of your inhaler.”
b. “Exhale fully before bringing the inhaler to your lips.”
c. “Depress the canister after you inhale.”
d. “Do not shake your inhaler before use.”
b. “Exhale fully before bringing the inhaler to your lips.”
69
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick day rules. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will monitor my blood glucose every 8 hours.”
b. “I will not take my diabetes medications while I am sick.”
c. “I will check my urine ketones if my blood glucose is greater than 240 mg/dL.”
d. “I will consume 250 grams of carbohydrates daily while I’m sick.”
c. “I will check my urine ketones if my blood glucose is greater than 240 mg/dL.”
70
A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect?
a. pH 7.38
b. PaO2 85 mm Hg
c. PaCO2 48 mm Hg
d. HCO3 25 mEq/L
c. PaCO2 48 mm Hg
71
A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse?
a. Presence of intrinsic P waves following QRS complex on the ECG
b. Hiccups
c. Sneezing
d. Presence of a sharp spike prior to the ORS complex on the ECG
b. Hiccups
72
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?
a. Valproic acid
b. Metformin
c. Fluticasone
d. Metoprolol
b. Metformin
73
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?
a. Place the pillows under the client’s knees.
b. Apply compression stockings to the lower extremities.
c. Avoid use of anticoagulants.
d. Discourage leg exercises while in bed.
b. Apply compression stockings to the lower extremities.
74
A nurse is caring for a client who has a duodenal ulcer. Which of the following actions should the nurse take? (Click the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
a. Offer a snack before bedtime.
b. Administer the client’s naproxen prescription.
c. Restrict the client’s fluid intake to 1,000 mL/day.
d. Infuse packed RBC’s.
d. Infuse packed RBC’s.
75
A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse’s priority?
a. “I’ve noticed that there is a gray ring around the colored part of my eye.”
b. “In the last day, I have had a severe headache and pain around my right eye.”
c. “I’m having more difficulty telling the difference between blues and greens.”
d. “I can’t seem to get reading materials far enough away to see the words.”
b. “In the last day, I have had a severe headache and pain around my right eye.”
76
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate?
a. Potassium 6.8 mEq/L
b. Creatinine 0.4 mg/dL
c. Hgb 20 g/dL
d. BUN 8 mg/dL
a. Potassium 6.8 mEq/L
77
A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan?
a. Limit the client’s fluid intake to 1,500 mL/day.
b. Administer aspirin if the client reports a headache.
c. Encourage the client to change positions slowly.
d. Perform range-of-motion exercises to the client’s neck every 4 hr.
c. Encourage the client to change positions slowly.
78
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hit spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Spot B at the top of abdomen left side
79
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
a. Prepare the client for an intravenous pyelogram.
b. Insert a urinary catheter.
c. Initiate beta blocker therapy.
d. Administer IV fluids to the client.
d. Administer IV fluids to the client.
80
A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?
a. Complete the transfusion within 2 hr.
b. Slow the transfusion rate if the client reports itching.
c. Prime the IV tubing with 0.45% sodium chloride.
d. Administer through a 22-gauge IV catheter.
a. Complete the transfusion within 2 hr.
81
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
a. Increase phosphorus intake.
b. Decrease carbohydrate intake.
c. Increase potassium intake.
d. Decrease protein intake.
d. Decrease protein intake.
82
A nurse is caring for an older adult client who has dementia. Which of the questions should the nurse ask to assess the client’s abstract thinking?
a. “What do you understand about your condition?”
b. “Can you tell me the state where you were born?”
c. “Can you count backwards from 100 in intervals of 7?”
d. “What is meant by the saying, “Don’t beat around the bush?”
d. “What is meant by the saying, “Don’t beat around the bush?”
83
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
a. Instruct visitors to remain 3 feet from the client.
b. Discard the radioactive device in the client’s trash can.
c. Keep soiled bed linens in the client’s room.
d. Limit time for visitors to 2 hr per day.
c. Keep soiled bed linens in the client’s room.
84
A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?
a. Attach a dosimeter badge to the client’s gown.
b. Move the client’s soled linens to a designated container outside the room.
c. Place long-handled forceps at the client’s bedside.
d. Leave unused equipment in the client’s room until discharge.
a. Attach dosimeter badge to the client’s gown.
85
A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
a. Hypotension
b. Decreased heart rate
c. Lethargy
d. Increase temperature
d. Increase temperature
86
A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client what which of the following immunizations are recommended for healthy adults after age 60? (SATA)
a. Human papillomavirus.
b. Pneumococcal polysaccharide.
c. Influenza
d. Herpes zoster
e. Meningococcal.
b. Pneumococcal polysaccharide.
c. Influenza
d. Herpes zoster
87
A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
a. Weight gain
b. Loss of skin turgor
c. Hypotension
d. Bradycardia
a. Weight gain
88
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?
a. Admin phenytoin IV bolus to the client.
b. Provide the client O2 at 6 L/min using a nasal cannula.
c. Admin diazepam IV to the client.
d. Turn the client to the lateral position during seizure activity.
d. Turn the client to the lateral position during seizure activity.
89
A nurse is assessing a client who has a new diagnosis of type 1 DM. Which of the following findings indicate that the client is experiencing hypoglycemia?
a. Fruity odor to breath
b. Increased perspiration
c. Abdominal cramping
d. Dehydration
b. Increased perspiration
90
A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment findings is the nurse’s priority?
a. Hypotension.
b. Weakness to the lower extremities.
c. Hypoactive bowel sounds.
d. Bladder distention.
a. Hypotension.
91
A nurse is caring for a client following a cardiac catheterization who has hives and urticarial following the admin of IV contrast dye. Which of the following meds should the nurse plan to administer?
a. Spironolactone
b. Diphenhydramine
c. Desmopressin
d. Metoclopramide
b. Diphenhydramine
92
A nurse is caring for a client who is postop following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. Serosanguinous drainage.
b. Client report of incisional pain.
c. Client report of nausea.
d. Muscle twitching.
d. Muscle twitching.
93
A nurse is caring for a female client who is receiving TPN without fat emulsion. Which of the following findings should the nurse report?
a. Triglyceride 110 mg/dL.
b. Weight gain of 1.3 kg (3 lbs.) over the past 7 days.
c. Bowel sounds absent in lower quadrants.
d. Crackles in the bilateral lung bases.
d. Crackles in the bilateral lung bases.
94
A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use?
a. Pain relief from the use of heat and cold continues for several hours
after removal of the stimulus.
b. Use imagery with clients who have difficulty with focus and concentration.
c. Discontinue opioids before trying nonpharmacological methods of pain relief.
d. Distraction changes the client’s perception of pain, but doesn’t affect the cause.
c. Discontinue opioids before trying nonpharmacological methods of pain relief.
95
A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?
a. Indistinct, rambling speech
b. Piloerection of the skin
c. Decreased body temperature
d. Vomiting upon arousal
d. Vomiting upon arousal
96
A nurse is caring for a client following a below the knee amputation. The client states, “My life is over.” Which of the following responses should the nurse make?
a. “Would you like to meet with another client who is an amputee?”
b. “You are upset. We can talk about this later.”
c. “Most people can adjust following this surgery.”
d. “Why do you think your life is over?”
d. “Why do you think your life is over?”
97
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
a. Assist the client with toileting at least once every 4 hours.
b. Request a prescription for a nightly sedative.
c. Place the client’s bed at the lowest height.
d. Turn off all lights in the client’s room at night
c. Place the client’s bed at the lowest height.
98
A nurse is teaching about measures to prevent recurring UTIs with a female client. Which of the following info should the nurse include in the teaching? (SATA)
a. Take a warm bubble bath daily.
b. Drink 3 L of fluids daily
c. Drink low fructose cranberry juice
d. Void every 6 hours during the day.
e. Wipe the perineal area from front to back after urinating
b. Drink 3 L of fluids daily
c. Drink low fructose cranberry juice
e. Wipe the perineal area from front to back after urinating
99
A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position the nurse should assist the client into for this procedure?
Lateral recumbent or sitting upright
100
A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify that which of the following rhythms indicate bradycardia?
slow rhythm, spaced out PQRST
101
A nurse is caring for a client who has a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?
a. Remove the wedge divide when turning
b. Encourage the client to lean forward when attempting to stand
c. Place two bed pillows between the legs when in bed
d. Elevate the knees higher than the hips when sitting
c. Place two bed pillows between the legs when in bed
102
A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?
a. Insert a large bore nasogastric tube
b. Ensure that the client has a 22-gauge IV line in place
c. Administer nitroprusside IV based on the client's weight
d. Provide ketorolac for abdominal pain
a. Insert a large bore nasogastric tube
103
A nurse is preparing to administer piperacillin 3.375 g by intermittent IV bolus every 6 hr. Available is piperacillin 3.375 g in dextrose 5% in water (D5W) 100 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? Round to the nearest whole number
200
104
A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH 7.24, PaCO2 44 mm Hg, Pa02 84 mmHg, HCO3 18 mEq/L, base excess-2 and 02 saturation 95%. The nurse should conclude that the client has which of the following acid base imbalance?
a. Metabolic alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Respiratory alkalosis
c. Metabolic acidosis
105
A nurse is teaching a client who has endometriosis about adverse effects of leuprolide. Which of the following manifestations should the nurse include in the teaching?
a. Increased appetite
b. Hypoglycemia
c. Bone Loss
d. Pallor
c. Bone Loss
106
A nurse is providing teaching to a client who recently had a myocardial infarction and has a new prescription for nitroglycerin sublingual tablet to manage chest pain at home. Which of the following client statements indicates an understanding of the teaching?
a. I should wait 20 minutes between taking the tablets
b. I can keep the tablets in my plastic pill box
c. I should replace my open bottle of tablets every 6 months
d. I can take up to 4 tablets when I have chest pain
c. I should replace my open bottle of tablets every 6 months
107
A nurse is preparing to perform gastric lavage for a client who has a
bleeding gastric ulcer. Which of the following equipment should the nurse plan to use for the procedure?
Image of a rolled-up tube
108
A nurse is planning the discharge of a client who has an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?
a. Diuretic
b. Antithrombotic
c. Anticonvulsant
d. Opioid analgesic
b. Antithrombotic
109
A nurse is planning care for an older adult client who has Meniere’s disease (vertigo). Which of the following interventions should the nurse include in the plan?
a. Administer aspirin if the client reports a headache
b. Encourage the client to change positions slowly
c. Perform range of motion exercises to the clients neck every 4 hours
d. Limit the client's fluid intake to 1,500 mL/day
b. Encourage the client to change positions slowly
110
A nurse is assessing a client who has pericarditis. In which of the following areas of the client's chest should the nurse place the stethoscope to best hear a pericardial friction rub?
a. IMAGE: The pericardial rub is best auscultated with the diaphragm of
the stethoscope over the left lower sternal border in end expiration
with the patient leaning forward. It has a rasping or creaking sound
similar to leather rubbing against leather.
111
A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?
a. Place the client supine
b. Perform neurological assessments
c. Begin an IV bolus of lactated ringers
d. Initiate an IV dopamine infusion
b. Perform neurological assessments
112
A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us”
b. “It's going to be difficult to tell my parents i can't take them to their appointments anymore”
c. “There crutches will make it impossible to care for my child”
d. “I feel bad that i have to ask my partner to keep the house clean”
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us”
113
A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the clients abstract thinking?
a. “Can you count backwards from 100 in intervals of 7?”
b. “Can you tell me the state where you were born?”
c. “What is meant by the saying don't beat around the bush?”
d. “What do you understand about your condition?”
c. “What is meant by the saying don't beat around the bush?”
114
A nurse is reviewing discharge teaching with a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?
a. I will increase green leafy vegetables in my diet
b. I know this medication increase my risk for blood clots
c. I should avoid taking acetaminophen while taking this medication
d. I will return in 1 month to have my blood tested
d. I will return in 1 month to have my blood tested
115
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take?
a. Instruct the client to avoid eating raw fruit
b. Move the client to a negative pressure room
c. Use contact isolation while providing care
d. Apply pressure to venipuncture sites for 10 min
a. Instruct the client to avoid eating raw fruit
116
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
a. The client reports a pain level of 7 on a scale from 0 to 10 at the
operative site.
b. The client has 100 mL blood in the closed suction drain
c. The clients capillary refill in the left toe is 6 seconds
d. The client has an oral temperature of 38.3 C (100.9 F)
c. The clients capillary refill in the left toe is 6 seconds
117
A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching?
a. Monitor urinary output for retention
b. Restrict fluid intake if you experience constipation
c. Itching indicates you are having an allergic reaction to the
medication
d. Avoid taking antiemetics with the medication
a. Monitor urinary output for retention
118
A nurse in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has first degree heart block?
a. Prolonged PR intervals
b. Indiscernible P waves
c. More P waves than QRS complexes
d. No correlation between P and QRS waves
a. Prolonged PR intervals
119
A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?
a. I will weigh myself daily
b. I'm too tired to brush my teeth
c. I hate how i feel all the time
d. I need to start eating a low sodium diet
b. I'm too tired to brush my teeth
120
A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered dose inhaler. Which of the following client statements indicates an understanding of the teaching?
a. I should wait 15 seconds between puffs
b. I should clean the cap of the inhaler once per week
c. I should shake the inhaler before I use it
d. I should inhale the medication quickly
c. I should shake the inhaler before I use it
121
A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. High fowlers
c. Side lying
d. Feet elevated
d. Feet elevated
122
A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?
a. Headache
b. Flushed skin color
c. Heat intolerance
d. Bradycardia
a. Headache
123
A nurse is caring for a client who has cancer. The client tells the nurse, “I would prefer to try vitamins and minerals instead of chemotherapy” which of the following responses should the nurse make?
a. Tell me what you know about chemotherapy
b. I have never heard of any holistic treatment that is effective
c. You should ask your provider about your plan
d. The best way to treat your cancer is chemotherapy
a. Tell me what you know about chemotherapy
124
A nurse is caring for a client in the emergency department who experienced a full thickness burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect?
a. Urinary diuresis
b. Hypotension
c. Bradycardia
d. Decreased respiratory rate
b. Hypotension
125
A nurse is providing preoperative teaching for a client who is having left sided cardiac catheterization. Which of the following information should the nurse include in the teaching?
a. You should plan to remain in bed for 18 hours after the procedure
b. You will have blood pressure measurements every 5 minutes for the first 2 hours after the procedure
c. You will receive a general anesthetic during the procedure
d. You should expect a warm sensation after the injection of the contrast dye during the procedure
d. You should expect a warm sensation after the injection of the contrast dye during the procedure
126
A nurse is caring for a client who has ulcerative colitis. After the admission assessment and diagnostics, which of the following actions is the nurse's priority? EXHIBIT
a. Administer hydrocortisone sodium succinate
b. Request a referral for a dietitian
c. Obtain a prescription for an antidiarrheal medication
d. Administer two units of packed RBC
d. Administer two units of packed RBC
127
A nurse is planning care for a client who has a central venous access device for intermittent infusions, which of the following actions should the nurse include in the plan of care?
a. Flush the catheter using a 10 mL syringe
b. Change the dressing every 24 hours
c. Use clean technique when changing the dressing
d. Cleanse the site with povidone iodine
a. Flush the catheter using a 10 mL syringe
128
A nurse is planning care for a client who has full thickness burns on the lower extremities. Which of the following interventions should the nurse include?
a. Clean the equipment in the clients room once per week
b. Apply new gloves when alternating between wound care sites
c. Limit visitation time for the clients children to 40 min per day
d. Provide a diet of fresh fruits and vegetables for the client
b. Apply new gloves when alternating between wound care sites
129
A nurse is assessing a client admitted with peripheral vascular disease. Which of the following findings indicates a venous vascular disorder?
a. Leg pain at rest
b. Hair loss distal to the clients calves
c. Anulceronthetipifatoe
d. Edema of the ankle
d. Edema of the ankle
130
A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?
a. Remove soiled linens from the room after each change
b. Limit family member visit to 30 min/day
c. Give the dosimeter badge to the oncoming nurse at the end of the shift
d. Apply a second pair of gloves before touching the clients implant of it dislodges
b. Limit family member visit to 30 min/day
131
A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?
a. Itching over the incision
b. Irregular heart rate
c. Distended neck veins
d. Diminished breath sounds
d. Diminished breath sounds
132
A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?
a. Start the infusion at 30 mEq/hr
b. Monitor the client for adequate urine output
c. Assess the client for a positive Chvostek sign
d. Check the infusion site at least every 4 hr.
b. Monitor the client for adequate urine output
133
A nurse is caring for a client who has an arterial revascularization of the right lower extremity. Which of the following is the priority action the nurse should plan to take after contacting the provider? EXHIBIT
a. Start an IV fluid bolus of 0.9% sodium chloride 500 mL to infuse of 1 hr.
b. Increase the heparin infusion rate per protocol
c. Increase the insulin infusion rate per protocol
d. Change the PCA timing of the patient control bolus to every 15 min.
a. Start an IV fluid bolus of 0.9% sodium chloride 500 mL to infuse of 1 hr.
134
A nurse is preparing to administer 2 units of packed RBC to a client. Which of the following actions should the nurse take?
a. Transfer each unit of blood over 5 hr
b. Prime the tubing with 0.9 sodium chloride
c. Change the IV tubing after each unit of blood is transfused
d. Administer the blood through a 22-gauge intravenous catheter.
b. Prime the tubing with 0.9 sodium chloride
135
A nurse is preparing to administer Naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lb. The amount available is 0.4 mg/mL. How many mL should the nurse administer? Round to the nearest tenth.
2.5
136
A nurse is caring for a client who is postoperative following endoscopy with moderate sedation. Which of the following assessment findings is the nurse's priority?
a. Level of pain
b. Warmth of extremities
c. Gag reflex
d. Temperature
c. Gag reflex
137
A nurse in the emergency department is caring for a client who was involved in an explosion. Which of the following actions should the nurse plan to take first? EXHIBIT
a. Calculate the extent of burns using the rule of nines
b. Obtain a ECG
c. Initiate peripheral IV access
d. Notify the rapid response team
c. Initiate peripheral IV access
138
A nurse is reviewing a cardiac rhythm strip of a client who has an atrial flutter. Which of the following findings should the nurse expect?
a. A saw tooth pattern with atrial rate of 250 to 400/min
b. Progressively longer PR durations
c. Undetectable P waves
d. Absent PR intervals with ventricular rate of 40-60/min
a. A saw tooth pattern with atrial rate of 250 to 400/min
139
A nurse is providing discharge teaching about blood glucose monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies?
a. Sterile lancets
b. Hand mirror
c. Compression stockings
d. Toenail clippers
a. Sterile lancets
140
A nurse is caring for a client who has just undergone a total laryngectomy. Which of the following findings is the nurse's priority for immediate intervention?
a. IV infiltration
b. Tachypnea
c. Fever
d. Blood-tinged secretions
a. IV infiltration
141
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
a. Insert a urinary catheter
b. Initiate beta blocker therapy
c. Prepare the client for an intravenous pyelogram
d. Administer IV fluids to the client
d. Administer IV fluids to the client
142
A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?
a. A client who reports having fever, night sweats, and cough for 2 days
b. A client who has a compound fracture of the right femur
c. An older adult client who was admitted with aspiration pneumonia
d. A client who has diabetes mellitus and is presenting with acute
ketoacidosis
a. A client who reports having fever, night sweats, and cough for 2 days
143
A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the clients skin. Which of the following actions should the nurse take?
a. Institute bleeding precautions
b. Avoid administering IV pain medications
c. Determine the client's blood type
d. Implement airborne precautions
a. Institute bleeding precautions
144
A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following?
a. Aspiration
b. Pleural effusion
c. Fluid volume excess
d. Increased cardiac output
c. Fluid volume excess
145
A nurse in an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?
a. Obtain consent for surgery
b. Insert an NG tube
c. Apply antiembolic stockings
d. Insert an indwelling urinary catheter
b. Insert an NG tube
146
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports bladder spasms and the nurse observes urinary output. Which of the following actions should the nurse take?
a. Flush the catheter manually with 0.9% sodium chloride
b. Remove the indwelling urinary catheter
c. Administer ibuprofen 400 mg for pain relief
d. Decrease traction on the catheter
a. Flush the catheter manually with 0.9% sodium chloride
147
A home health nurse is teaching a client how to care for a peripherally inserted central catheter in the right arm. Which of the following statements should the nurse include in the teaching?
a. Change the transparent dressing over the insertion site every 48
hours
b. See the provider within 72 hours to have sutures removed
c. Clean the insertion site with mild soap and water
d. Use a 10-milliliter syringe when flushing the catheter
d. Use a 10-milliliter syringe when flushing the catheter
148
A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home, when discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?
a. Fever
b. Increased heart rate
c. Generalized abdominal pain
d. Cloudy effluent
d. Cloudy effluent
149
A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first?
a. Initiate cardiac monitoring for the client
b. Establish an IV access
c. Palpate for the client's carotid pulse
d. Apply a blood pressure cuff
c. Palpate for the client's carotid pulse
150
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
a. Respiratory status
b. Surgical site
c. Pain level
d. Level of consciousness
a. Respiratory status
151
A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross reactivity to which of the following substances
a. Anesthetics
b. Adhesive tape
c. Latex
d. Povidone iodine
c. Latex
152
A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications?
a. Pantoprazole
b. Acetaminophen
c. Diphenhydramine
d. Furosemide
d. Furosemide
153
A nurse is reviewing the medication list of a client who is being admitted with diabetes insipidus. Which of the following medications places the client at an increased risk for developing diabetes insipidus?
a. Ranitidine
b. Lithium
c. Propranolol
d. Atorvastatin
b. Lithium
154
A nurse is planning to teach a client whose provider has prescribed a low purine diet. The nurse should plan to instruct the client that he can include which of the following foods in his diet? [SATA]
a. Scallops
b. Apricots
c. Sardines
d. Nuts
e. Liver
b. Apricots
| d. Nuts
155
A nurse is assessing a client who has a new diagnosis of colon cancer. Which of the following findings should the nurse expect?
a. Steatorrhea
b. Weight gain
c. Elevated hemoglobin
d. Hematochezia
d. Hematochezia
156
A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?
a. Leave the door to the clients room open
b. Wear a lead apron when providing client care
c. Place the dosimeter film badge on the clients door
d. Allow visitor to hold the client's hand
b. Wear a lead apron when providing client care
157
A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following is the priority topic for the nurse to review with the client?
a. Fluid intake record
b. Daily sodium restrictions
c. Changes in weight
d. Daily exercise routine
c. Changes in weight
158
A nurse is preparing to infuse dextrose 5% in 0.45% sodium chloride 500 mL IV bolus over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? Round to the nearest whole number
125
159
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
a. Sodium 136 mEq/L
b. BUN 18 mg/dL
c. Creatinine 0.8 mg/dL
d. Potassium 3.2 mEq/L
d. Potassium 3.2 mEq/L
160
A nurse is teaching a client who has AIDS and wishes to continue self- care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
a. Initiate a referral for the client to a home health agency
b. Tell the client to avoid places where there are large crowds of people
c. Remind the client of the importance of medication adherence
d. Instruct the client to avoid eating raw vegetables
a. Initiate a referral for the client to a home health agency
b. Tell the client to avoid places where there are large ?????
161
A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? [SATA]
a. Measure the amount of the dialysate outflow
b. Raise the drainage bag above the level of the client's abdomen
c. Elevate the client to the high fowler’s position
d. Monitor the access site for drainage
e. Reposition the client onto the other side
a. Measure the amount of the dialysate outflow
d. Monitor the access site for drainage
e. Reposition the client onto the other side
162
A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium?
a. 1 cup white rice
b. 2 tbsp peanut butter
c. 1 medium baked potato with skin
d. ó cup nonfat yogurt
a. 1 cup white rice
163
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?
a. Administer proparacaine eye drops into the affected eye
b. Collect information about the irritating that caused the injury
c. Instill 0.9% sodium chloride solution into the affected eye
d. Place a strip of pH paper onto the cul-de-sac of the affected eye
c. Instill 0.9% sodium chloride solution into the affected eye
164
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
a. I should expect my lesions should resolve in 6 weeks
b. I should apply antibiotic ointment to the lesions
c. I should expect to take my medications for 3 weeks
d. I should use natural skin condoms during sexual intercourse
b. I should apply antibiotic ointment to the lesions
165
A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first?
a. Blood pressure
b. Urinary output
c. Motor responses
d. Blood glucose
a. Blood pressure
166
A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication for receiving Heparin?
a. Thrombocytopenia
a. Thrombocytopenia
167
A nurse is caring for a client who has pancreatitis and has been receiving TPN. Which of the following laboratory tests should the nurse monitor for overall nutritional status?
a. Prealbumin
a. Prealbumin
168
A nurse is caring for a client in DKA. Which of the following is the priority intervention by the nurse?
a. Check potassium levels
a. Check potassium levels
169
A nurse is teaching a client who has asthma about the use of a peak flow meter. After setting the meter to the zero baseline, what is the sequence of steps the nurse should instruct the client to take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
a. Stand upright
b. Fill your lungs with a deep breath
c. Seal your lips around the mouthpiece
d. Exhale forcefully and quickly
e. Record the highest of 3 consecutive readings
a. Stand upright
b. Fill your lungs with a deep breath
c. Seal your lips around the mouthpiece
d. Exhale forcefully and quickly
e. Record the highest of 3 consecutive readings
170
A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions?
a. Ask the client to empty his bladder prior to the procedure
a. Ask the client to empty his bladder prior to the procedure
171
A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long term diabetes?
a. A1c glycated hemoglobin
a. A1c glycated hemoglobin
172
A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
a. Wear cotton rather than nylon socks
a. Wear cotton rather than nylon socks
173
A nurse is assessing a client who has pericarditis, in which of the following areas of the client's chest should the nurse place the stethoscope to hear pleural friction rub?
a. Erb's point (3rd intercostal) option that's on the left lower
a. Erb's point (3rd intercostal) option that's on the left lower
174
A nurse is planning a staff education session about hepatitis A. Which of the following information should the nurse include?
a. Immunization for Hep A is recommended prior to travel
a. Immunization for Hep A is recommended prior to travel
175
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
a. Dark red granulation tissue
b. Light yellow exudate
c. Dry brown eschar
d. Wound tissue firm to palpation
a. Dark red granulation tissue
176
A nurse is assessing a client who has a new diagnosis of diverticulitis and report that he uses multiple complementary therapies. Which of the following therapies should the nurse identify as a contraindication for the client?
a. Acupuncture
a. Acupuncture
177
A nurse is assessing a client who has cirrhosis. Which of the following findings is a priority for the nurse to report?
a. Platelet 70,000 (low)
a. Platelet 70,000 (low)
178
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?
a. Admin phenytoin IV bolus to the client.
b. Provide the client O2 at 6 L/min using a nasal cannula.
c. Admin diazepam IV to the client.
d. Turn the client to the lateral position during seizure activity.
d. Turn the client to the lateral position during seizure activity.
179
A nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse's priority?
a. Obtain a blood specimen for culture and sensitivity testing
a. Obtain a blood specimen for culture and sensitivity testing
180
A nurse is caring for a client who has a chest tube. The client asks why does the fluid and the water seal chamber rise and fall. Which of the following statement should the nurse make?
a. Your breathing pattern causes this
a. Your breathing pattern causes this
181
A nurse is providing teaching for a client who has a DVT. Which of the following findings should the nurse identify as a risk factor of the development for DVT?
a. Oral Contraceptives
a. Oral Contraceptives
182
A nurse is administering furosemide 80 mg to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective?
a. Weight loss of 1.8 kg (4 lbs) in the past 24 hrs
a. Weight loss of 1.8 kg (4 lbs) in the past 24 hrs
183
A nurse is caring for a client with a total knee arthroplasty. The client reports a pain level of 6 out of 10. Which of the following interventions should the nurse take?
a. Apply ice pack to the client's knee
a. Apply ice pack to the client's knee
184
A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
a. I will be sure to wear gloves and wash my hands when I change my cat's litter box
a. I will be sure to wear gloves and wash my hands when I change my cat's litter box
185
A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?
a. Cool clammy skin
a. Cool clammy skin
186
A nurse is caring for a client who has advanced liver disease. Which of the following laboratory tests should the nurse monitor when assessing the client?
a. Serum ammonia
a. Serum ammonia
187
A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when planning the client's meals?
a. Offer frequent high-carb meals
a. Offer frequent high-carb meals
188
A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?
a. A client who has thrombocytopenia and reports a nose bleed
a. A client who has thrombocytopenia and reports a nose bleed
189
A nurse is assessing a client who has right sided heart failure. Which assessment finding is expected?
a. Pitting Edema
a. Pitting Edema
190
A nurse is caring for a female client who has toxic shock syndrome. Which of the findings should the nurse expect?
a. Generalized rash
a. Generalized rash
191
A nurse is caring for a client who is 6 hours post op following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?
a. Palpate the dorsalis pedis pulse
a. Palpate the dorsalis pedis pulse
192
A nurse is reviewing a medical record of a client CT scan with contrast media. Which of the following medication should the nurse instruct the client to withhold within 48 hours?
a. Metformin
a. Metformin
193
A nurse is in an emergency department reviewing EG readings. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block?
a. Prolonged PR interval
a. Prolonged PR interval
194
A nurse is monitoring a client who is receiving 2 units of packed RBC. Which of the following manifestation indicated a hemolytic transfusion reaction?
a. Back pain
a. Back pain
195
A nurse is caring or a client who is postmenopausal and is receiving hormone replacement therapy. Which of the following adverse effect of this medication should be reported by the client has the highest priority?
a) Calf pain
b) Weight gain
c) Menstrual spotting
d) Breast tenderness
a) Calf pain
196
A nurse is providing foot care to a client with diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
a) I will wear cotton socks every day
b) I will wear foot powder after my socks
c) I should inspect my feet at least once a week.
d) I should wear snug fitting shoes
a) I will wear cotton socks every day
197
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
a) I should expect my lesions should resolve in 6 weeks
b) I should apply antibiotic ointment to the lesions
c) I should expect to take my medications for 3 weeks
d) I should use natural skin condoms during sexual intercourse
b) I should apply antibiotic ointment to the lesions
198
A nurse working in the coronary care unit is monitoring a client who had a myocardial infarction 6 hours ago. Which of the following heart rhythms a priority finding?
a) Sustained ventricular tachycardia
b) First degree atrio ventricular block
c) Right bundle branch block
d) Premature atrial contracture
a) Sustained ventricular tachycardia
199
A nurse is caring for a client who has peptic ulcer disease. Which of the following assessment findings indicates perforation of the peptic ulcer?
a) Rigid board like abdomen
b) Hypertension
c) Hyperactive bowel sounds
d) Dull aching pain in lower quadrants
a) Rigid board like abdomen
200
A nurse is teaching a client who is preoperative for a total knee arthroplasty about using a flow-oriented incentive spirometer after his surgery. Which of the following instructions should the nurse give the client?
a) Try to force the flow meter into the base of the spirometer
b) Avoid coughing during the spirometer session
c) Breathe into the spirometer at least 15 times per minute
d) Hold his breath for 3 to 5 seconds at maximum inspiration
d) Hold his breath for 3 to 5 seconds at maximum inspiration
201
A nurse is caring for a client who is brought to the emergency room after sustain deep partial thickness and full thickness burn over 45% of his body after the client’s airway is stabilized the nurse next priority is
a) Intravenous fluid replacement
b) Antibiotic replacement
c) Gain control
d) Aseptic wound care
a) Intravenous fluid replacement
202
A nurse is performing a routine peripheral IV dressing change and notes that the client’s insertion site is cool to touch. The client reports burning sensation at the site. Which of the following interventions should the nurse take?
a) Place the extremity in a dependent position
b) Use an arm board to secure the extremity
c) Restart the infusion using a different infusion site
d) Flush the line with 0.9% sodium chloride
c) Restart the infusion using a different infusion site
203
A nurse is caring for a client who has a prescription for 4 units of regular insulin and 6 units NPH insulin daily at 0700. At 0630 the client’s blood glucose is 248mg/dl. Which of the following actions should the nurse take?
a) Administer 4 units regular and 6 units NPH
b) Withhold 4 units regular insulin until after the clients breakfast
c) Administer 4 units regular insulin and withhold 4 units NPH
d) Withhold 6 units of NPH until after breakfast
a) Administer 4 units regular and 6 units NPH
204
A nurse is providing discharge teaching to a client who has a new sigmoid colostomy. Which of the following instructions should the nurse include?
a) Choose a time shortly after a meal for replacing the pouch
b) Expect the consistency of the stool to be loose to pasty
c) Use moisturizing soap and water to clean around the stoma
d) Empty the pouch when it is one third to one half full
d) Empty the pouch when it is one third to one half full
205
A client present to the emergency department with shortness of breath without exertion. Based on the client information provided.
a) Decreased radioactive iodine uptake
b) Elevated serum T3
c) Low antibody tither
d) Increased TSH
b) Elevated serum T3
206
A nurse is providing discharge teaching to a client who has neutropenia. Which of the following statements by the client indicates understanding of the teaching?
a) I will bathe using antibacterial soap
b) I will increase fresh fruits and vegetables in my diet
c) I will use an electric shaver when shaving
d) I will keep a water bottle at my bedside during the night
c) I will use an electric shaver when shaving
207
A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
a) I should place a nitroglycerin tablet under my tongue every 10 mins for up to four doses
b) I should lie down before taking a dose of isosorbide dinitrate
c) I should take my aspirin on an empty stomach
d) I should withhold my metoprolol if my heart rate is above 100 bpm
b) I should lie down before taking a dose of isosorbide dinitrate
208
A nurse is reviewing lab results of a client who has Crohn’s disease. Which of the following results should the nurse report to the provider?
a) WBC count 8,100/mm3
b) BUN 18mg/dL
c) ESR 15mm/hr
d) RBC count 3.9/mm3
d) RBC count 3.9/mm3
209
A nurse is caring for a client who has a pneumothorax and has a chest tube to closed chest water seal drainage and suction. The nurse should monitor the water seal chamber for which of the following indicating an air leak?
a) 2 cm (3/4 inch) of water present in the chamber
b) Continuous bubbling
c) Water rises 7.6 cm (3 in) on inhalation
d) Tidaling is present
b) Continuous bubbling
210
A nurse is caring for a client who has a new prescription of lisinopril (Zestril) The nurse should recognize which of the following actions are appropriate when administering their medication?
a) Monitor for hypotension for the first 5 hours
b) Assess for clinical manifestations of hypokalemia
c) Allow ambulation as desired
d) Elevate the head of the bed at 30o
a) Monitor for hypotension for the first 5 hours
211
A nurse is caring for a client admitted for dehydration related to Crohn’s disease. The client is experiencing diarrhea and vomiting, and reports abdominal pain. Which of the following dietary recommendations should the nurse take?
a) High fat
b) High protein
c) High lactose
d) High fiber
b) High protein
212
A nurse in the emergency department is admitting a client who reports a visual disturbance in the left eye. The client reports that it began with a flash of light followed by a partial loss of vision. The nurse should recognize that this clinical manifestation is indicative of which of the following?
a) Corneal laceration
b) Optic neuritis
c) Retinal detachment
d) Conjunctival hemorrhage
c) Retinal detachment
213
A nurse is providing teaching for a client who is to undergo a glycosylated hemoglobin test (HbA1c). Which of the following information should the nurse include?
a) “The test will indicate anemia due to loss of intrinsic factor”
b) “This is an oral glucose test that is used for diagnosing diabetes”
c) “This test shows the average blood glucose levels for the past 120 days.”
d) “This test will measure the percentage of the RBC in your total blood volume”
c) “This test shows the average blood glucose levels for the past 120 days.”
214
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports a sharp, abdominal pain. Which of the following actions should the nurse take first?
a) Check the client’s urine output
b) Reposition the client in bed
c) Re-tape the catheter to the client’s abdomen
d) Administer PRN pain medication
a) Check the client’s urine output
215
A nurse is planning care for a client who has diabetes insipidus. Which of the following actions is appropriate for the nurse to include in the clients plan of care?
a) Restrict fluid intake to 550 ml/24 hr
b) Administer vasopressin (Pitressin)
c) Infuse 0.3% sodium chloride IV
d) Monitor for pulmonary edema
b) Administer vasopressin (Pitressin)
216
A nurse is providing teaching to a client who has chronic kidney disease. Which of the following client statements indicates an understanding of the teaching?
a) “I will increase my protein intake”
b) “I will drink 1.5 liters of water each day”
c) “I will eat foods high in potassium”
d) “I will weight myself every day”
d) “I will weight myself every day”
217
A nurse is caring for a client in the ER. Which of the following client reports should lead the nurse to suspect an aortic dissection?
a) Abrupt, severe back pain
b) Intermittent back pain
c) Moderate abdominal pain relieved by movement
d) Mild abdominal pain that recurs frequently
a) Abrupt, severe back pain
218
A nurse is providing post-op care for a client following a knee arthroplasty. Which of the following actions should the nurse implement?
a) Immobilize the affected extremity
b) Perform neurovascular assessments every 2 hours
c) Administer diuretics for 24 hr following surgery
d) Apply warm, moist heat packs to the knee
a) Immobilize the affected extremity
219
A nurse is caring for a client who is receiving peritoneal dialysis.Upon assessment, the nurse notes a temperature of 102 F and abd distention. Which of the following actions should the nurse take? [SATA]
a) Assess the color and amount of the dialysate outflow
b) Ensure that the outflow bag is above the client’s abdomen
c) Auscultate bowel sounds
d) Check the peritoneal catheter for patency
e) Monitor the access site for drainage
a) Assess the color and amount of the dialysate outflow
d) Check the peritoneal catheter for patency
e) Monitor the access site for drainage
220
A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following lab values should the nurse report to the surgeon?
a) Platelets 95,000/mm3
b) Hct 42%
c) WBC 8000/mm3
d) INR of 1.6
a) Platelets 95,000/mm3
221
A nurse in the ER is performing mass casualty range. Which of the following clients should receive treatment first?
a) A client who has an open fracture of the femur
b) A client who has multiple abrasions on the abdomen
c) A client who has a right sided tracheal deviation
d) A client who has a 7.6 cm (3 inch) scalp laceration
c) A client who has a right sided tracheal deviation
222
A nurse is caring for a client who is scheduled to receive hemodialysis and has an internal arteriovenous (AV) graft in the left forearm. Which of the following is an appropriate intervention to verify adequate circulation on the AV graft?
a) Assess proximal pulse
b) Palpate skin temperature over the graft site
c) Auscultate for a bruit
d) Obtain blood pressure from the left arm
c) Auscultate for a bruit
223
A nurse is assessing a client who has left sided heart failure. Which of the following findings should the nurse expect?
a) Right upper quadrant pain
b) Dependent edema
c) Pulmonary congestion
d) Jugular vein distention
c) Pulmonary congestion
224
A nurse is caring for an older adult client who has cardiomyopathy and has developed acute pulmonary edema. Which of the following is the priority action by the nurse?
a) Place the client upright in bed
b) Admin IV morphine sulphate
c) Contact the client’s provider
d) Admin IV furosemide (Lasix)
d) Admin IV furosemide (Lasix)
225
A client’s infusion pump has alarmed several times and the nurse suspects a problem with the system. Which of the following actions should the nurse take first?
a) Reset the infusion rate
b) Flush the catheter
c) Aspirate the catheter for a blood return
d) Check for kinks in the IV tubing
d) Check for kinks in the IV tubing
226
A nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following findings should indicate to the nurse that the client’s airway requires suctioning?
a) Low pressure alarm sounding on the ventilator
b) Pulse ox sat of 94%
c) Decreased peak airway inspiratory pressure
d) Rhonchi noted upon auscultation
d) Rhonchi noted upon auscultation
227
A nurse is caring for a client following a total left knee arthroplasty. The provider prescribes the use of a continuous passive motion (CPM) machine. Which of the following actions should the nurse include in the plan of care?
a) Check circulation of the extremity at least every 10 hours
b) Initiate CPM immediately after the surgery
c) Apply heat to the affected extremity while using the CPM machine
d) Check the motion setting cycles every 12 hours
b) Initiate CPM immediately after the surgery
228
A nurse is caring for a client who has fluid volume excess. Which of the following assessment findings is the priority concern?
a) Bounding pulses
b) Basilar crackles
c) Dependent edema
d) Headache
b) Basilar crackles
229
A nurse is caring for a client following a radial neck surgery for laryngeal cancer. Which of the following behaviors is most indicative that the client is adapting to the body image change?
a) The client is willing to touch his neck area
b) The client states he will attend a support group
c) The client displays an absence of facial tension
d) The client verbalizes reduced anxiety
a) The client is willing to touch his neck area
230
A nurse is assessing a client’s response to morphine sulfate 4mg intermittent IV bolus. Which of the following findings indicates a hypersensitivity that the nurse should report to the provider?
a) Dizziness
b) Respirations 10/min
c) Drowsiness
d) Urticaria
d) Urticaria
231
A nurse is caring for a client who has thrombocytopenia. Which of the following lab results should the nurse expect?
a) PT 11 seconds
b) aPPT 40 seconds
c) Platelets 70,000/mm3
d) INR of 1.0
c) Platelets 70,000/mm3
232
A nurse is planning care for a client who has cervical cancer and has implanted radiation seeds. Which of the following interventions should the nurse include in the plan of care?
a) Ensure a lead lined container is available in the client’s room
b) Dispose of urine in a special receptacle
c) Wear an isolation cover gown when providing care
d) Allow visitors to remain up to 1 hr daily
a) Ensure a lead lined container is available in the client’s room
233
A nurse is monitoring a client who has a prescription to remain flat for 8 hr after spinal surgery. Which of this following should alert the nurse to the possibility of cerebrospinal fluid leakage?
a) Reduced sensation in the lower extremities
b) Severe headache
c) Sanguineous drainage on the dressing
d) Lumbar pain
b) Severe headache
234
A home health nurse is making an initial visit to an older adult client who has a vision impairment. Which of the following interventions should the nurse suggest to help keep the client safe at home?
a) Encourage the use of a standard stove rather than a microwave
b) Place routine medications in color coded containers
c) Install long, soft-surfaced carpeting
d) Paint the edge of the top and bottom staircase steps in a bright color
d) Paint the edge of the top and bottom staircase steps in a bright color
235
A nurse is caring for a client who has deep vein thrombosis and is on bed rest. The client reports shortness of breath and rapid heartbeat. Which of the following actions should the nurse take?
a) Administer oxygen via a face mask
b) Place a pillow under the client’s knees
c) Lower the head of the client’s bed
d) Apply a warm, moist pack to the affected leg
a) Administer oxygen via a face mask
236
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate and has a continuous bladder irrigation. Which is appropriate for the nurse to delegate to assistive personnel?
a) Regulate the rate of continuous bladder irrigation
b) Assess the color of the urine in the catheter bag
c) Document the amount of bladder irrigation instilled
d) Measure the output of the bladder irrigation in the catheter bag
d) Measure the output of the bladder irrigation in the catheter bag
237
A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?
a) A client who has a peripherally inserted central catheter (PICC) in the left forearm
b) A client who has left-sided Bell’s palsy
c) A client who has right-sided weakness due to Parkinson’s disease
d) A client who has a right upper extremity arteriovenous fistula
d) A client who has a right upper extremity arteriovenous fistula
238
A nurse is providing teaching to an adult client who presents for a physical examination. Which of the following statements by the client indicates a need for further teaching?
a) “My pap smear was negative last year”
b) “I had a baseline colonoscopy 4 years ago.
c) “I perform breast self-examinations every 2 months.”
d) “I get annual mammograms”
c) “I perform breast self-examinations every 2 months.”
239
A nurse is caring for a client who is prescribed anti-embolism thigh-high stockings. The largest size available is too tight for the client. Which of the following actions should the nurse take?
a) Place the stockings on the lower part of the legs.
b) Loosen the elastic to stretch the stockings
c) Position the client with pillows beneath the knees
d) Apply elastic wraps to the entire length of the legs
d) Apply elastic wraps to the entire length of the legs
240
A nurse is caring for a client with an implanted port. Which of the following should the nurse select to access this device?
a) Filter needle
b) Catheter tip syringe
c) Luer-lok syringe
d) Non-corning needle
d) Non-corning needle
241
A nurse is planning to provide dietary counseling for a client who has uric acid kidney stones. Which of the following foods should the client exclude from the diet?
a) Citrus fruits
b) Organ meats
c) Dairy products
d) Leafy vegetables
b) Organ meats
242
A nurse is caring for a client who is 2hr postop following a thyroidectomy. Which of the following actions should the nurse take?
a) Monitor the client hourly for tetany
b) Discourage the client from coughing and deep breathing
c) Position the client supine without a pillow
d) Maintain the client NPO for 12 hr following surgery
a) Monitor the client hourly for tetany
243
A nurse is caring for a client who had a gastrectomy. After eating, the client displays symptoms of early dumping syndrome. To prevent future episodes of gastric dumping, the nurse should implement which of the following?
a) Encourage fluid intake with meals
b) Ambulate client immediately following meals
c) Offer a high calorie milk shake during meals
d) Place the client in a supine position after meals
d) Place the client in a supine position after meals
244
A nurse is developing a teaching plan for an older adult client who is prescribed an oral hypoglycemic agent. Which of the following should the nurse include in the teaching?
a) Reduce activity when blood glucose rises
b) Take an extra pill after eating a large meal
c) Eat meals at a consistent time each day
d) Monitor and document body weight daily
c) Eat meals at a consistent time each day
245
A nurse is performing a focused assessment on a client with a history of skin cancer. Which of the following skin lesions found by the nurse requires immediate follow up care?
a) A raised lesion with irregular, notched borders
b) Multiple, ruby-red papules scattered over the chest and trunk
c) A 4 mm vesicle that appears to contain pus
d) A flat, 1 mm nonpalpable reddish-brown lesion
a) A raised lesion with irregular, notched borders
246
A nurse has received a prescription for 70% oxygen for a client who is experiencing difficulty breathing. Which of the following images indicate the appropriate equipment to supply the client with the prescribed amount of oxygen?
Non-Rebreather
247
A nurse is caring for a client who has nephrotic syndrome and a decreased glomerular filtration rate. When planning meals for the client, which of the following foods should the nurse plan to restrict?
a) Eggs
b) Orange juice
c) Brown rice
d) Raw carrots
a) Eggs
248
A nurse is giving a community presentation about preventing the transmission of HIV. In discussing condom use, the nurse should include which of the following guidelines?
a) Remove the condom while the penis is still erect
b) Apply petroleum jelly to lubricate the condom
c) Use natural membrane condoms for vaginal intercourse
d) Store condoms in a warm environment
a) Remove the condom while the penis is still erect
249
A nurse is providing discharge teaching to a client who has thrombophlebitis and is prescribed lovenox. Which of the following instructions should the nurse include in the teaching?
a) Use a 22-gauge needle to administer the medication
b) Massage the area gently following the injection
c) Inject the medication into the vastus lateralis muscle
d) Use a 3/8th in long needle to administer the medication
d) Use a 3/8th in long needle to administer the medication
250
A nurse is caring for an older adult client who has primary open angle glaucoma. Which of the following findings should the nurse anticipate?
a) Loss of peripheral vision
b) Constricted pupils
c) Diplopia
d) Yellow spots on the retina
a) Loss of peripheral vision
251
A nurse is reviewing the morning lab results for a client with end-stage kidney disease who is receiving hemodialysis. Which of the following lab values is the highest priority?
a) Arterial PaCO2 of 32 mm Hg
b) Serum magnesium of 2.2 mEq/L
c) Arterial bicarbonate of 20 mEq/L
d) Serum potassium of 5.5 mEq/L
d) Serum potassium of 5.5 mEq/L
252
A nurse is assessing a client who has cancer and is receiving chemotherapy. The client is also receiving Epogen. Which of the following statements by the client indicates effectiveness of the medication?
a) I have more energy now
b) My constipation has resolved
c) I notice that I urinate more often
d) I don’t get nauseated after I eat
a) I have more energy now
253
A nurse is caring for a client who is post op following a total knee arthroplasty and has an autologous blood salvage drain system. Which of the following should the nurse include in the plan of care?
a) Monitor for incompatibility infusion reaction when infusing the salvaged blood
b) Administer the salvaged blood using micro drip IV tubing
c) Store the salvaged blood in the refrigerator up to 24 hours
d) Infuse the salvaged blood within 6 hours
b) Administer the salvaged blood using micro drip IV tubing
254
A nurse is evaluating the results of a Mantoux skin test. The site shows a 10 mm induration after 72 hr. Which of the following actions should the nurse take next?
a) Instruct the client to provide three sputum specimens on his next visit.
b) Instruct the client that this finding indicates the need for a chest x-ray.
c) Instruct the client about isoniazid (INH) therapy.
d) Instruct the client about airborne precautions.
b) Instruct the client that this finding indicates the need for a chest x-ray.
255
A nurse is caring for a client who has thoracic outlet syndrome. Which of the following should the nurse recognize as an expected clinical manifestation with the diagnosis?
a) Ischemic finger pain at night.
b) Numbness when holding arms up.
c) Digital ulcerations.
d) Continual neck pain.
d) Continual neck pain.
256
A nurse is caring for a client with a new peripherally inserted central catheter. Before starting an infusion, the nurse should review the results of which of the following to verify tip placement?
a) Ultrasound
b) Blood aspiration
c) Chest x-ray
d) Computed tomography
c) Chest x-ray
257
A nurse is caring for a client who is receiving a unit of packed RBCs. The nurse suspects the client is having an acute intravascular hemolytic reaction. Which of the following actions should the nurse take? (Order the steps of the process by placing the letters in the correct sequence.)
a) Obtain blood and urine specimens.
b) Stop the infusion.
c) Initiate IV infusion of 0.9% sodium chloride.
d) Remove blood administration tubing.
B,D,C,A
258
A nurse is caring for a client who is receiving epinephrine IM. Which of the following findings is an adverse effect of the medication?
a) Serum blood glucose 92 mg/dL
b) Blood pressure 102/104 mm Hg
c) Heart rate 64/min
d) Respirations 22/min
b) Blood pressure 102/104 mm Hg
259
A nurse is providing education to a client being discharged with multiple prescriptions, including furosemide (Lasix) and digoxin (Lanoxin). Which of the following statements by the client indicates understanding of the medication administration?
a) “I will be sure to take my Lanoxin pill before I exercise to prevent chest pain.”
b) “I can’t take my digoxin and Lasix at the same time, so I’ll take one in the morning and the other one at night.”
c) “Now that I’m taking Lanoxin and Lasix, I will be sure to eat foods that are high in potassium, like bananas.”
d) “If I get sick and the doctor puts me on antibiotics, I won’t take my Lanoxin pill until I take all the antibiotics.”
c) “Now that I’m taking Lanoxin and Lasix, I will be sure to eat foods that are high in potassium, like bananas.”
260
A nurse is administering naloxone (Narcan) to a client for the treatment of an opioid overdose. Which of the following findings indicates the medication is effective?
a) Decrease in heart rate.
b) Decrease in pain.
c) Increase in drowsiness.
d) Increase in respiratory rate.
d) Increase in respiratory rate.
261
A nurse in a post anesthesia care unit is caring for a client following a cardiac catheterization. Which of the following is an appropriate action by the nurse?
a) Assess the insertion site every 2 hr.
b) Check the pedal pulse of the affected extremity.
c) Place the client in high-Fowler’s position.
d) Ambulate the client within 1 hr.
b) Check the pedal pulse of the affected extremity.
262
A nurse is providing teaching about total parenteral nutrition (TPN) to a client newly diagnosed with Crohn’s disease. Which of the following statements by the client indicates that the teaching has been effective?
a) “The IV tubing needs to be changed every 72 hr.”
b) “My blood glucose will be checked every few hours.”
c) “I need to be weighed once a week.”
d) “My TPN can be stopped every 2 hr.”
b) “My blood glucose will be checked every few hours.”
263
A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?
a) Provide the client with a short handled reacher.
b) Place the client’s bedside table on the left side.
c) Ambulate the client with a standby assist.
d) Place a plate guard on the client’s tray.
d) Place a plate guard on the client’s tray.
264
When analyzing an ECG rhythm strip, a nurse should do which of the following first?
a) Measure the QRS duration.
b) Determine the heart rhythm.
c) Measure the PR interval.
d) Determine the heart rate.
b) Determine the heart rhythm.
265
A nurse is providing teaching for a client who is to start therapy with isoniazid (INH) and rifampin (RIF) for active tuberculosis. Which of the following should the nurse include in the teaching?
a) “You will need to take medication for 6 to 12 months.”
b) “Notify the provider if your urine is discolored.”
c) “Take the medications with meals.”
d) “The provider will adjust your dosage weekly based on sputum
specimen results.”
a) “You will need to take medication for 6 to 12 months.”
266
A nurse is teaching a client who has irritable bowel syndrome (IBS) about self-management strategies. Which of the following information should the nurse include in the teaching? [SATA]
a) Drink 240 mL (8 oz) of fluid with each meal.
b) Maintain a food diary to identify dietary triggers.
c) Limit high fiber foods.
d) Chew food slowly and thoroughly
e) Practice relaxation techniques to reduce stress.
b) Maintain a food diary to identify dietary triggers.
d) Chew food slowly and thoroughly
e) Practice relaxation techniques to reduce stress.
267
A nurse is assisting with the care of a client who has hypomagnesemia and is receiving magnesium sulfate IV. Which of the following findings should indicate to the nurse that the medication is effective?
a) Temperature of 37.3C (99.2F)
b) Lung sounds clear bilaterally.
c) Brisk pupillary response.
d) 2+ deep tendon reflexes.
d) 2+ deep tendon reflexes.
268
A nurse is working in a telemetry unit is monitoring a client. Which of the following cardiac rhythms indicates the client is at risk for pulmonary embolism?
a) Premature ventricular complexes.
b) Sinus bradycardia.
c) Ventricular fibrillation.
d) Atrial fibrillation.
d) Atrial fibrillation.
269
A nurse working in a telemetry unit indicates an infusion of potassium chloride for a client who has hypokalemia. Which of the following indicates the treatment is effective?
a) Wide QRS complexes.
b) U-waves are absent
c) ST segment elevation
d) P-waves absent
b) U-waves are absent
270
A nurse is assessing a client following the client’s endotracheal tube. Which of the following findings should the nurse report to the provider immediately?
a) Hoarseness
b) Rhonchi
c) Stridor
d) Sore throat
c) Stridor
271
A nurse is planning care for an older adult client who has manifestations of dehydration. Which of the following interventions should the nurse include in the plan?
a) Administer furosemide IV
b) Offer oral fluids every 4 hr.
c) Check urinary output status every 6 hr.
d) Monitor for mental status changes.
d) Monitor for mental status changes.
272
A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and has received two units of packed RBCs. Which of the following findings indicates a therapeutic response?
a) SaO2 89%
b) Platelet count 140,000/mm3
c) Hemoglobin 13 g/dL
d) PT 13 sec
c) Hemoglobin 13 g/dL
273
A nurse is conducting a morning assessment on a client who is diagnosed with HTN. The nurse observes that the client has a constant cough. Upon review of the client’s medical record, which of the following medications should the nurse withhold?
a) Furosemide
b) KCL
c) Aspirin
d) Captopril
d) Captopril
274
A nurse on a cardiac unit is a ssessing a client who had an acute MI 6 hours ago. The nurse should monitor the client for signs of myocardial hypoperfusion, which include:
a) Systolic heart murmur
b) low-grade fever
c) Friction Rub
d) Ventricular dysrhythmia
d) Ventricular dysrhythmia
275
A nurse is instructing a client with left sided weakness who is using a quad cane to ambulate. Which of the following indicates a need for further teaching? [SATA]
a) The cane is held on the strong side of the body.
b) The cane moves the left leg to where the cane is positioned
c) The client advances the left leg prior to moving the cane.
d) The cane measures to the level of the greater trochanter
e) The cane is held on the left side.
b) The cane moves the left leg to where the cane is positioned
c) The client advances the left leg prior to moving the cane.
e) The cane is held on the left side.
276
A nurse on a medical-surgical unit is receiving a client who is 24 hours postop following CABG and has mediastinal chest tubes. Which of the following assessments is the priority?
a) O2 saturation
b) Chest tube drainage
c) LOC
d) Atrial heart rate.
a) O2 saturation
277
A nurse is caring for four clients, for which of the following clients should the nurse implement seizure precaution?
a) A client with a sodium level of 116 mEq/L
b) A client with a serum glucose level of 325 mg/dL
c) A client with a core temperature of 35.2oC (95.4oF)
d) A client with a potassium level of 3.8 mEq/L
a) A client with a sodium level of 116 mEq/L
278
A nurse is caring for client who is receiving TPN. The client weighs 220 lbs. and has a prescription for 2 g of protein per kg per day. Which of the following is the correct amount of protein the client should receive?
200 g
279
A nurse is performing chart audits to evaluate appropriate use of isolation precautions. Which of the following infections should the nurse identify as requiring airborne precautions?
a) Scabies
b) Clostridium difficile
c) Measles
d) Hepatitis C
c) Measles
280
A nurse is caring for a client who is receiving a unit of packed RBCs. Which of the following findings can indicate an allergic transfusion reaction?
a) Headache
b) Hemoglobinuria
c) Urticaria
d) Bounding pulse
c) Urticaria
281
A nurse is planning to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse plan to take?
a) Attach the bag to the rail to the bed
b) Collect a urine specimen from the drainage bag 1hr after insertion.
c) Raise the head of bed to 45 prior to insertion.
d) Secure the catheter to the client's inner thigh.
d) Secure the catheter to the client's inner thigh.
282
A nurse is planning a diet for a client who has stomatitis due to radiation therapy for stage 1 Hodgkin's lymphoma. Which of the following food should the nurse include in the client’s diet?
a) Yogurt with canned apricots
b) Fried potatoes with bacon
c) Orange juice with whole wheat toast
d) Granola with whole milk.
a) Yogurt with canned apricots
283
A nurse is caring for a client who is experiencing ventricular fibrillation. Which of the following is the priority action by the nurse?
a) Initiate chest compressions
b) Ventilate the client with a bag valve mask.
c) Defibrillate the client at 200 joules.
d) Administer vasopressin 40 Units IV
c) Defibrillate the client at 200 joules.
284
A nurse is caring for a client who has DM and is taking naproxen (Naprosyn) 250 mg twice daily. The client is at risk for which of the following?
a) Renal failure
b) Trigeminal myalgia
c) Hepatic cirrhosis
d) Rheumatoid arthritis
a) Renal failure
285
A nurse is caring for a client who has a radial arterial line. Which of the following is the priority assessment for the client?
a) Temperature of and sensation in the client's hand
b) Pressure of the fluid in the hemodynamic system
c) Level of the client's hemodynamic system transducer
d) Integrity of the arterial wave form.
a) Temperature of and sensation in the client's hand
286
A nurse is caring for a client who is 4hr post op following CABG. Which of the following should the nurse recognize as an expected finding following this procedure?
a) Chest tube drainage
b) Pitting edema in the sacral area
c) Crackles heard on auscultation
d) Urine output
a) Chest tube drainage
287
A nurse is providing teaching to a client who is receiving phenytoin (Dilantin) for seizures. Which of the following should the nurse include in the teaching?
a) Take medication with an antacid
b) Monitor for redness of the gums
c) Expect urine to turn blue.
d) Expect yellowing of the skin
b) Monitor for redness of the gums
288
A nurse is caring for four clients. Which of the following clients is at greatest risk for atelectasis?
a) A client on bed rest for 4 hours following a Lumbar puncture
b) A client who has a fractured femur and is ambulatory
c) A client recovering from general anesthesia after a colon resection
d) A client who has cellulitis and type 2 DM
c) A client recovering from general anesthesia after a colon resection
289
A nurse is caring for a client who is in the oliguria phase of Acute Renal Failure. Which of the following laboratory findings should the nurse report to the provider?
a) Creatinine of 1.1 mg/dL
b) Potassium of 5.8 mEq/L
c) Sodium of 135 mEq/L
d) BUN of 18 mg/dL
b) Potassium of 5.8 mEq/L
290
A nurse is completing a preoperative nursing assessment and learns that the client has been taking garlic as an OTC herbal supplement to lower cholesterol. For which of the following adverse effects should the nurse monitor the client?
a) Blood-clotting inhibition
b) Bradycardia
c) Cardiac dysrhythmias
d) Hypertension
a) Blood-clotting inhibition
291
A nurse is providing a discharge teaching to a client who has gout and is taking allopurinol (Zyloprim) Which of the following instructions should the nurse include in the teaching?
a) Avoid citrus fruits and juices
b) Eat a diet high in protein
c) Drink plenty of fluids
d) Take aspirin for headaches
c) Drink plenty of fluids
292
A nurse is caring for a client during an IV urography. Which of the following is the highest priority finding?
a) Swelling of the lips
b) Pain at the IV catheter insertion site
c) Decreased urine output
d) Suprapubic fullness
a) Swelling of the lips
293
A nurse is caring for a client who has a complete spinal cord injury before the 3rd cervical vertebra. When performing a sensory assessment, the nurse should expect a response to light touch at which of the following areas? (You will find selectable areas of “Hot Spots” by moving the cursor over the picture)
(You will find selectable areas of “Hot Spots” by moving the cursor over the picture)
