Review

Question 1

A nurse is planning to meet with the interprofessional team about the care of a client who has a new diagnosis of ulcerative colitis. Which of the following recommendations should the nurse plan to make during the meeting?

A. “The client should be referred to pain management.”
B. “The client should be referred to hospice services.”
C. “The client should be referred to a wound, ostomy, and continence nurse.”
D. “The client should be referred to a dietitian.”

Answer 1

D. “The client should be referred to a dietitian.”

Question 2

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

A. Inability to smell
B. Loss of peripheral vision
C. Disequilibrium with movement
D. Deviation of the tongue from midline

Answer 2

C. Disequilibrium with movement

Question 3

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. Diphenhydramine
B. Ondansetron
C. Sertraline
D. Methylprednisolone

Answer 3

B. Ondansetron

Question 4

A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?

A. Chlorpromazine
B. Dobutamine
C. Mannitol
D. Propranolol

Answer 4

C. Mannitol

Question 5

A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?

A. Pedal edema
B. Neck vein distention
C. Daytime oliguria
D. Enlarged liver

Answer 5

C. Daytime oliguria

Question 6

A nurse enters a client’s room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

A. Turn the client on their side.
B. Perform a neurologic check.
C. Obtain the client’s vital signs.
D. Notify the rapid response team.

Answer 6

A. Turn the client on their side.

Question 7

A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?

A. Joint inflammation
B. Tophi
C. Esophagitis
D. “Bull’s eye” lesion

Answer 7

A. Joint inflammation

Question 8

A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

A. Initiate IV fluid replacement.
B. Measure the client’s urinary output.
C. Administer insulin.
D. Teach the client about manifestations of HHS

Answer 8

A. Initiate IV fluid replacement.

Question 9

A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?

A. Stool for occult blood
B. Fasting blood glucose
C. Serum calcium
D. Urine for white blood cells

Answer 9

A. Stool for occult blood

Question 10

A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. Which of the following food allergies indicates a risk for an allergic reaction to latex?

A. Strawberries
B. Eggs
C. Peanuts
D. Shellfish

Answer 10

A. Strawberries

Question 11

A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?

A. Chloride level
B. Creatinine kinase
C. Uric acid
D. Intrinsic factor

Answer 11

C. Uric acid

Question 12

A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances?

A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis

Answer 12

C. Metabolic alkalosis

Question 13

A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

A. Provide humidified oxygen.
B. Administer antibiotic medication.
C. Implement fluid restriction
D. Administer acetaminophen orally.

Answer 13

A. Provide humidified oxygen.

Question 14

A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?

A. Place the client in a supine position.
B. Administer antihypertensive medications.
C. Monitor the client for hypercalcemia.
D. Maintain the client on NPO status.

Answer 14

D. Maintain the client on NPO status.

Question 15

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A. Administer oxygen to the client.
B. Collect a urine sample.
C. Stop the infusion.
D. Check the client’s vital signs.

Answer 15

C. Stop the infusion.

Question 16

A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client’s safety?

A. Loss of hearing
B. Muscle wasting
C. Paresthesia
D. Changes in vision

Answer 16

C. Paresthesia

Question 17

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

A. Emesis of 250 mL
B. Increased respiratory rate to 26/min
C. Decreased anxiety
D. Decreased urinary output

Answer 17

C. Decreased anxiety

Question 18

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. A history of herpes zoster
B. Taking amlodipine for hypertension
C. Using a nicotine transdermal patch
D. Eating a strict vegetarian diet

Answer 18

C. Using a nicotine transdermal patch

Question 19

A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client’s airway, which of the following interventions should the nurse take first?

A. Increase the room temperature.
B. Cleanse the client’s wounds.
C. Administer analgesic medication.
D. Start an IV with a large-bore needle.

Answer 19

D. Start an IV with a large-bore needle.

Question 20

A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?

A. “I will take this medication with fiber to prevent constipation.”
B. “I will notify my provider if I experience muscle weakness.”
C. “I will increase my dose if my vision becomes blurred.”
D. “I will take my digoxin if my pulse is less than 50 beats per minute.”

Answer 20

B. “I will notify my provider if I experience muscle weakness.”

Question 21

A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

A. Hypertension
B. 2+ edema
C. Crackles in lungs
D. Tachycardia

Answer 21

D. Tachycardia

Question 22

A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?

A. “These discomforts should decrease with time.”
B. “Women your age experience thickening of the vaginal tissue.”
C. “Your symptoms are likely due to decreasing estrogen levels.”
D. “You should avoid intercourse to prevent injury to your vagina.”

Answer 22

C. “Your symptoms are likely due to decreasing estrogen levels.”

Question 23

A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

A. The client asks for help before ambulating.
B. The client has a history of urinary incontinence.
C. The client lives with their caregiver.
D. The client has bronchitis.

Answer 23

B. The client has a history of urinary incontinence.

Question 24

A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?

A. Gentle bubbling in the water seal chamber
B. Drainage and warmth at tube insertion site
C. Crackling sensation felt around tube insertion site
D. Drainage output less than 70 mL/hr

Answer 24

A. Gentle bubbling in the water seal chamber

Question 25

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take? A. Use an elevated toilet seat. B. Log roll the client onto the operative side. C. Keep client's affected heel on the bed. D. Perform internal and external rotation exercises of hip.

Answer 25

A. Use an elevated toilet seat.

Question 26

A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report? A. Neck stiffness B. Hoarseness C. Moderate serosanguineous drainage D. Muscle twitching

Answer 26

D. Muscle twitching

Question 27

A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown? A. Receiving bronchodilator medication B. Weight loss of 2.8 kg (6.2 b) C. Hemoglobin 17 g/dl (12 to 16 g/dL) D. Wearing an oxygen device

Answer 27

B. Weight loss of 2.8 kg (6.2 b)

Question 28

A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take? A. Monitor vital signs at least every 4 hr. B. Insert an indwelling urinary catheter. C. Change the client's linens three times a day. D. Place the client in a room with negative airflow.

Answer 28

A. Monitor vital signs at least every 4 hr.

Question 29

A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown? A. Hgb 18 g/dL (12 to 16 g/dl) B. WBC 12.000/mm3 (5,000 to 10,000/mm3) C. 25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL) D. Albumin 3.1 g/dL (3.5 to 5 g/dL)

Answer 29

D. Albumin 3.1 g/dL (3.5 to 5 g/dL)

Question 30

A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer? A. Naloxone B. Protamine sulfate C. Acetylcysteine D. Flumazenil

Answer 30

A. Naloxone

Question 31

A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider? A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply a vest restraint daily at bedtime to prevent nighttime wandering. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply soft heel protectors bilaterally while client is in bed.

Answer 31

B. Apply a vest restraint daily at bedtime to prevent nighttime wandering.

Question 32

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output? A. Weight gain B. Distended abdomen C. Confusion D. Dyspnea

Answer 32

C. Confusion

Question 33

A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition? A. Alopecia B. Diplopia C. Oily skin D. Increased salivation

Answer 33

A. Alopecia

Question 34

A charge nurse is observing a newly licensed nurse care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA). Which of the following observations of the newly licensed nurse indicates an understanding of infection control precautions? A. Remains 3 feet away from the client B. Wears an N95 mask when providing wound care C. Disposes of isolation gown outside of the client's room D. Wears clean gloves when caring for the client

Answer 34

D. Wears clean gloves when caring for the client

Question 35

A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? A. This medication may cause my blood pressure to increase." B. "I should take an antacid with each dose of this medication." C. "I plan to take this medication for 1 week." D. "I will have my liver function tested while I am taking this medication."

Answer 35

D. "I will have my liver function tested while I am taking this medication."

Question 36

A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching? A. "I will ensure their neck is flexed backwards when they're lying on their stomach." B. "I will support their feet with a rolled pillow when they are lying on their back." C. "I will rest their heels on the mattress when they are sitting up in bed." D. "I will use a thick pillow under their head to support the neck."

Answer 36

B. "I will support their feet with a rolled pillow when they are lying on their back."

Question 37

A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement? A. Ensure the client's bed is positioned to greater than 45°. B. Initiate airborne precautions. C. Ensure lights are dimmed in the client's room. D. Encourage frequent ambulation.

Answer 37

C. Ensure lights are dimmed in the client's room.

Question 38

A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective? A. Respiratory rate of 16/min B. Decrease in blood pressure C. Increase in urinary output D. Blood glucose of 110 mg/dL

Answer 38

B. Decrease in blood pressure

Question 39

A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? A. Suction the client's airway. B. Empty water from the client's ventilator tubing. C. Increase the client's ventilator flow rate. D. Evaluate the client for a cuff leak.

Answer 39

D. Evaluate the client for a cuff leak.

Question 40

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.) A. Increase the rate of infusion if administration is delayed. B. Monitor serum blood glucose during infusion. C. Verify the solution with another RN prior to infusion. D. Infuse 0.9% sodium chloride if the solution is not available. E. Obtain the client's weight daily.

Answer 40

B. Monitor serum blood glucose during infusion. C. Verify the solution with another RN prior to infusion. E. Obtain the client's weight daily.

Question 41

A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication? A. Orange juice B. Beef stew C. Kale D. Yogurt

Answer 41

C. Kale

Question 42

A nurse is reviewing the client's diagnostic results and vital signs. Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. Which of the following actions should the nurse take? Select all that apply. A. Anticipate client to be prepped for cardiac catheterization. B. Assist with a continuous heparin infusion. C. Encourage the client to ambulate. D. Anticipate an increased dosage of metoprolol. E. Obtain a prescription for client to be NPO. F. Request a prescription for an antibiotic.

Answer 42

A. Anticipate client to be prepped for cardiac catheterization. B. Assist with a continuous heparin infusion. D. Anticipate an increased dosage of metoprolol. E. Obtain a prescription for client to be NPO.

Question 43

A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection? A. Monitor the client's temperature once every 6 hr. B. Make sure the client's room has positive-pressure airflow. C. Wear an N95 respirator when providing direct client care. D. Make sure dietary plates and utensils are disposable.

Answer 43

B. Make sure the client's room has positive-pressure airflow.

Question 44

The nurse is reviewing the client's medical record. Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. History: Which of the following findings indicates the client's condition has improved? Select all that apply. A. Blood pressure B. Echocardiogram results C. Respiratory rate D. Pain level E. Oxygenation saturation F. Urinary output G. Heart rate

Answer 44

A. Blood pressure C. Respiratory rate D. Pain level E. Oxygenation saturation G. Heart rate

Question 45

The nurse is reviewing the client's medical record. Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. The nurse should first address the client's _______ followed by the client's _____.

Answer 45

pain level ECG results

Question 46

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. 12-lead electrocardiogram: tachycardia with ST segment elevation and T wave changes Chest x-ray: lungs are clear in all lobes A . Metoprolol 15 mg IV bolus B . Oxygen at 2 L/min via nasal cannula C . Draw electrolytes along with Hgb and Hct D . Morphine 6 mg IV bolus every 3 hr as needed for pain E . Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses F . Obtain daily weight G . Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60

Answer 46

A . Metoprolol -NONESSENTIAL B . Oxygen - ANTICIPATED C . Draw electrolytes - NONESSENTIAL D . Morphine - ANTICIPATED E . Nitroglycerin - ANTICIPATED F . Obtain daily weight - NONESSENTIAL G . Atropine - CONTRAINDICATED

Question 47

A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make? A. "Contact your pharmacy to inquire about a different medication." B. "You should ask your provider to prescribe a cheaper medication." C. "I can arrange for a social worker to talk with you before you leave." D. "I can contact the occupational therapist to schedule a home visit."

Answer 47

C. "I can arrange for a social worker to talk with you before you leave."

Question 48

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, i had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate is irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds. Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Answer 48

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client is diaphoretic and short of breath. Heart rate is irregular and tachycardic.

Question 49

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Select the four findings that require immediate follow-up. A. Blood glucose level B. Bowel sounds C. Blood pressure D. Pain level E. Electrocardiogram findings F. Lung sounds G. Troponin T level

Answer 49

C. Blood pressure D. Pain level E. Electrocardiogram findings G. Troponin T level

Question 50

A nurse is caring for a client who weighs 190 lb and is receiving total parenteral nutrition. If the RDA of protein is 0.8 g/kg of body weight, how many grams of protein should the client receive daily? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 50

69

Question 51

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following is correct? A. Administer the transfusion through a 25-gauge saline lock. B. Transfuse the plasma over 4 hr. C. Hold the transfusion if the client is actively bleeding. D. Administer the plasma immediately after thawing.

Answer 51

D. Administer the plasma immediately after thawing.

Question 52

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include? A. Use moisturizing lotion while massaging the client's bony prominences. B. Instruct the client to sit on a rubber ring when seated in a chair. C. Place pillows between the client's knees when in a side-lying position. D. Raise the head of the client's bed to a 90° angle.

Answer 52

C. Place pillows between the client's knees when in a side-lying position.

Question 53

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? A. A client who has pancreatitis reports pain in the left shoulder. B. A client who has peritonitis reports generalized abdominal pain. C. A client who is postoperative reports incisional pain. D. A client who has angina reports substernal chest pain.

Answer 53

A. A client who has pancreatitis reports pain in the left shoulder.

Question 54

A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, "I am afraid to have this procedure." Which of the following responses should the nurse make? A. "Are you afraid of needles that will be used during the procedure?" B. "Let's discuss your concerns about this procedure." C. "Tell me why you are scared to have this procedure." D. "After this procedure, you will feel much better."

Answer 54

B. "Let's discuss your concerns about this procedure."

Question 55

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care? A. Maintain peripheral IV access. B. Pad the upper two side rails of the client's bed. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside.

Answer 55

B. Pad the upper two side rails of the client's bed.

Question 56

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration? A. Distended jugular veins B. Increased blood pressure C. Decreased blood pressure D. Pitting, dependent edema

Answer 56

C. Decreased blood pressure

Question 57

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 potassium intake. B. Decrease protein intake. C. Increase phosphorus intake. D. Decrease carbohydrate intake.

Answer 57

B. Decrease protein intake.

Question 58

A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism? A. Massage the client's legs every 4 hr while they are awake. B. Encourage the client to perform circumduction of the feet. C. Limit the client's fluid intake to 2,000 mL daily. D. Keep the client's knees in a flexed position while they are in bed.

Answer 58

B. Encourage the client to perform circumduction of the feet.

Question 59

A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority? A. Neurovascular assessment B. Pain assessment C. Braden scale D. Morse Fall Risk scale

Answer 59

A. Neurovascular assessment

Question 60

A nurse is caring for a client in the emergency department. Client came to the ED this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite. Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants, Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply. A. Respiratory alkalosis B. Septic shock C. Hypotension D. Cardiac arrhythmias E. Renal failure F. Cerebral edema

Answer 60

C. Hypotension D. Cardiac arrhythmias E. Renal failure F. Cerebral edema

Question 61

A nurse is caring for a client in the emergency department. Client came to the ED this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite. Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants, Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn. The client is at risk for developing ____ and ____

Answer 61

fluid volume deficit acute kidney injury

Question 62

Client came to the emergency department this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite. Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn. For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process. (HHS or DKA) A . Blood pH greater than expected reference range B . Urine ketones C . Skin turgor D . Creatinine greater than expected reference range E . Blood glucose greater than expected reference range

Answer 62

A . Blood pH greater than expected reference range - HSS B . Urine ketones - DKA C . Skin turgor - BOTH D . Creatinine greater than expected reference range - BOTH E . Blood glucose greater than expected reference range - BOTH

Question 63

A nurse is caring for a client in the emergency department. Which of the following 3 provider prescriptions does the nurse anticipate? A. Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L C. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L D. Regular insulin 20 units subcutaneously E. Blood glucose checks every 4 hr F. Initiate cardiac monitoring G. Insert indwelling urinary catheter H. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

Answer 63

B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L C. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L H. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

Question 64

A nurse is caring for a client in the emergency department. 1400: Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+, Blood glucose 310 mg/dl. (74 to 106 mg/dL) 1400: Temperature 36.8° C (98.2° F) Pulse rate 84/min Respiratory rate 16/min Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

Answer 64

Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bilateral pedal pulses 2+, Blood glucose 310 mg/dl. (74 to 106 mg/dL) Pulse rate 84/min Blood pressure 106/76 mm Hg

Question 65

Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst. The nurse should administer a total _____ sodium chloride in the first hour, _______ each subsequent hour.

Answer 65

1320 ml 880 ml

Question 66

Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst. The nurse should plan to first administer _______ followed by _____

Answer 66

0.9 % sodium chloride insulin

Question 67

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take? A. Lower the head of the bed to semi-Fowler's. B. Change infusion to lactated Ringer's and maintain rate. C. Slow infusion rate and contact the provider. D. Administer prescribed corticosteroids.

Answer 67

C. Slow infusion rate and contact the provider.

Question 68

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? A. Absence of a bruit B. Normotensive blood pressure C. Dilated appearance of the graft D. Palpable thrill

Answer 68

D. Palpable thrill

Question 69

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 hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer 69

midline top of abdomen

Question 70

A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take? A. Dispose of the top of the ampule in a sharps container. B. Expel air into the ampule to aspirate air bubbles. C. Place a paper towel around the ampule's neck to break off the top with both hands. D. Withdraw the medication from the ampule using a needleless system.

Answer 70

A. Dispose of the top of the ampule in a sharps container.

Question 71

A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect? A. Decreased coagulation B. Proteinuria C. Hyperalbuminemia D. Decreased serum lipid levels

Answer 71

B. Proteinuria

Question 72

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. Discard the radioactive device in the client's trash can. B. Keep soiled bed linens in the client's room. C. Instruct visitors to remain 3 feet from the client. D. Limit time for visitors to 2 hr per day.

Answer 72

D. Limit time for visitors to 2 hr per day.

Question 73

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 used 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.

Answer 73

C. Request an interpreter during the initial assessment.

Question 74

A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer? A. Urinary hesitancy B. Painless vaginal bleeding C. Unexplained weight gain D. Frequent diarrhea

Answer 74

B. Painless vaginal bleeding

Question 75

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? A. Wash hands with alcohol-based hand rub. B. Clean surfaces with chlorhexidine. C. Obtain a stool specimen with gloves. D. Place the client in a protective environment.

Answer 75

C. Obtain a stool specimen with gloves.

Question 76

A nurse is providing discharge teaching to a client who had a bilateral orchiectomy. The nurse should instruct the client to expect which of the following symptoms? A. Hypoglycemia B. Increased muscle mass C. Increased libido D. Hot flashes

Answer 76

D. Hot flashes

Question 77

A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the include? A. Avoid getting a flu vaccination. B. Limit fluids to 1.5 L per day. C. Limit alcohol intake to one drink per day. D. Avoid extremely hot or cold temperatures.

Answer 77

D. Avoid extremely hot or cold temperatures.

Question 78

A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching? A. "I can take another dose after 2 minutes." B. "I should take this medication as soon as the pain begins." C. "I should chew the tablet before I swallow it." D. "I can put the tablet against my cheek and gum."

Answer 78

B. "I should take this medication as soon as the pain begins."

Question 79

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 has 100 mL blood in the closed-suction drain. B. The client has an oral temperature of 38.3° C (100.9° F). C. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site. D. The client's capillary refill in the left toe is 6 seconds.

Answer 79

D. The client's capillary refill in the left toe is 6 seconds.

Question 80

A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take? A. Move the client up and down in bed by holding onto the halo traction device. B. Ensure that there is space for one finger to fit between the vest and the client's skin. C. Apply medicated powder under the vest to reduce itching. D. Loosen or tighten the screws on the device as needed for the client's comfort.

Answer 80

B. Ensure that there is space for one finger to fit between the vest and the client's skin.

Question 81

A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated? A. Phosphorus B. Triiodothyronine 3 C. Thyroid-stimulating hormone D. Calcium

Answer 81

B. Triiodothyronine 3

Question 82

A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client? A. "You will need to have the skin test annually." B. "You will need to follow up with your provider." C. "You will need to return in 48 hours for re-evaluation." D. "Your test will need to be repeated at this time."

Answer 82

B. "You will need to follow up with your provider."

Question 83

A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately? A. Sore throat B. SaO, 92% C. Stridor D. Rhonchi

Answer 83

C. Stridor

Question 84

A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver? A. Pursue local protective services. B. Take a nonprescription sleeping medication. C. Contact hospice services for end-of-life care. D. Consider respite care services.

Answer 84

D. Consider respite care services.

Question 85

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 to take an antiviral medication for 6 months." B. "You will need cryotherapy for 1 to 2 weeks." C. "You will need to be monitored for 15 minutes after receiving each medication dose." D. "You will need three follow-up blood tests within a 24-month period."

Answer 85

D. "You will need three follow-up blood tests within a 24-month period."

Question 86

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 keep you from seeing the surgical site." C. "The elastic bandage will keep the sutures from loosening." D. "The elastic bandage will prevent excessive edema."

Answer 86

D. "The elastic bandage will prevent excessive edema."

Question 87

A nurse is admitting a middle adult client who has cirrhosis. Findings upon admission: Exhibits The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. A . Spontaneous bruising B . Ascites C . Increased albumin level D . Hematemesis E . Elevated iron levels

Answer 87

A . Spontaneous bruising - WORSE B . Ascites - WORSE C . Increased albumin level - IMPROVE D . Hematemesis - WORSE E . Elevated iron levels - WORSE

Question 88

A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include? A. Keep the client's bedroom dark at night. B. Place a large-face clock in the client's bedroom. C. Cover electrical outlets in the client's home with tape. D. Hang a monthly calendar in the client's bedroom.

Answer 88

D. Hang a monthly calendar in the client's bedroom.

Question 89

A nurse is caring for an older adult client who was admitted with a urinary tract infection. Exhibits The nurse is assessing the client 12 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. A . Disoriented to person, place, and time B . Oxygen saturation 96% at 2 L/min via nasal cannula C . Hct 45% D . Butterfly rash E . Blood pressure 100/50 mm Hg

Answer 89

A . Disoriented - WORSE B . Oxygen saturation 96% - IMPROVE C . Hct 45% - IMPROVE D . Butterfly rash - UNRELATED E . Blood pressure 100/50 mm Hg - WORSE

Question 90

A nurse is asking a preoperative client about food allergies. Which of the following food allergies indicates a potential reaction to propofol? A. Strawberries B. Shellfish C. Avocados D. Eggs

Answer 90

D. Eggs

Question 91

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which of the following actions should the nurse take? A. Apply a cold compress to the suprapubic area. B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. D. Encourage the client to urinate every 2 hr.

Answer 91

A. Apply a cold compress to the suprapubic area.

Question 92

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first? A. Titrate IV fluids to maintain urine output at 75 mL/hr. B. Administer an opioid pain medication, C. Change dressings over the entrance and exit wounds. D. Obtain an ECG

Answer 92

D. Obtain an ECG

Question 93

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. A . Keep the client's head in a midline position B . Initiate seizure precautions C . Assist the client to the bathroom D . Elevate the head of the bed E . Encourage the client to cough F . Decrease oxygen to 1.5 L/min via nasal cannula

Answer 93

A . Keep the client's head in a midline position - ANTICIPATE B . Initiate seizure precautions - ANTICIPATE C . Assist the client to the bathroom - CONTRAINDICATED D . Elevate the head of the bed - ANTICIPATE E . Encourage the client to cough - NONESSENTIAL F . Decrease oxygen to 1.5 L/min via nasal cannula - CONTRAINDICATED

Question 94

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for a dietary consult. The client tells the nurse, "I will have to eat whatever the dietitian tells me." Which of the following statements by the nurse encourages the client's involvement in their plan of care? A. "I can assist you with making a list of foods you like for the dietitian." B. "I understand that the dietary choices can seem overwhelming." C. "Managing your diabetes will require you to make accommodations." D. "The dietitian will provide you with the best food choices to manage your diabetes."

Answer 94

A. "I can assist you with making a list of foods you like for the dietitian."

Question 95

A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would: A. Press down on the orbital area of the eye. B. Pinch the trapezius muscle. C. Use a 25-gauge needle. D. Elicit a reflex with a reflex hammer.

Answer 95

B. Pinch the trapezius muscle.

Question 96

A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the client's and family's cultural beliefs? A. "You should limit discussing past events with the client." B. "We will respect what is important to you." C. "We will arrange all burial services." D. "Grieving should not be done in front of the client."

Answer 96

B. "We will respect what is important to you."

Question 97

A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take? A. Irrigate the affected eye from the inner corner toward the outer corner. B. Sit the client up with their head turned toward the right side. C. Place a strip of pH paper under the upper lid of the affected eye. D. Irrigate the affected eye using sterile water.

Answer 97

A. Irrigate the affected eye from the inner corner toward the outer corner.

Question 98

A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement? A. Droplet precautions B. Standard precautions C. Airborne precautions D. Contact precautions

Answer 98

B. Standard precautions

Question 99

A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority? A. Gurgling bowel sounds every 10 seconds B. Centrally located umbilical protrusion C. Abdominal distention during breathing D. Rebound tenderness with palpation

Answer 99

D. Rebound tenderness with palpation

Question 100

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 has diabetes mellitus and is presenting with acute ketoacidosis B. An older adult client who was admitted with aspiration pneumonia C. A client who has a compound fracture of the right femur D. A client who reports having fever, night sweats, and cough for 2 days

Answer 100

D. A client who reports having fever, night sweats, and cough for 2 days

Question 101

A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity? A. A client who has a peripherally inserted central catheter (PICC) in the left arm 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

Answer 101

D. A client who has a right upper extremity arteriovenous fistula

Question 102

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? A. Cheyne-Stokes respirations B. Pupillary dilation C. Altered level of consciousness D. Decorticate posturing

Answer 102

C. Altered level of consciousness

Question 103

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 difficulty swallowing food." C. "I have a hard time with brushing my hair." D. "I would rather be in a wheelchair than use a walker to get around."

Answer 103

C. "I have a hard time with brushing my hair."

Question 104

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 the effectiveness of the teaching? A. "I should apply antibiotic ointment to the lesions." B. "I should use natural skin condoms during sexual intercourse." C. "I should expect my lesions to resolve in 6 weeks." D. "I should expect to take my medication for 3 weeks."

Answer 104

D. "I should expect to take my medication for 3 weeks."

Question 105

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first? A. Administer aspirin. B. Measure blood pressure. C. Administer nitroglycerin. D. Initiate IV access.

Answer 105

C. Administer nitroglycerin.

Question 106

A nurse is reinforcing teaching with a client who has osteoporosis and is prescribed (Fosamax) alendronate 70 mg PO weekly. Which of the following statements by the client indicates a need for further instruction? A. "I take my other pills at least 30 minutes after my alendronate." B. "I take my alendronate on the same day every week with an 8-ounce glass of milk." C. "I sit up and read the morning paper after taking my alendronate." D. "I will need to have a bone density test occasionally while taking this medication."

Answer 106

B. "I take my alendronate on the same day every week with an 8-ounce glass of milk."

Question 107

A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? A. "I'm going to include more cantaloupe in my diet." B. "I will check my pulse before I take the medication." C. "I will try to limit foods that contain salt." D. "I'll check my blood pressure so it doesn't get too high."

Answer 107

A. "I'm going to include more cantaloupe in my diet."

Question 108

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make? A. "This means your lung is fully re-expanded." B. "Your breathing pattern causes this." C. "Suction pressure that is too high causes this." D. "This indicates a possible air leak."

Answer 108

B. "Your breathing pattern causes this."

Question 109

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? A. Respiratory rate of 24/min B. Adventitious breath sounds C. Weight loss of 1.8 kg (4 lb) in the past 24 hours D. Elevation in blood pressure

Answer 109

C. Weight loss of 1.8 kg (4 lb) in the past 24 hours

Question 110

A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response? A. Laryngeal edema B. Fever C. Hypertension D. Arrhythmia

Answer 110

A. Laryngeal edema

Question 111

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication that the client is no longer infectious? A. Mantoux skin test revealing an induration of less than 1 mm B. Negative sputum cultures for acid-fast bacillus C. The client is no longer coughing up blood-tinged sputum D. Positive Quantiferon-TB Gold test (negative)

Answer 111

B. Negative sputum cultures for acid-fast bacillus

Question 112

A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority? A. The client requires assistance with getting dressed. B. The client reports numbness of the fingers of the left hand. C. The client reports itching of the left arm. D. The client has a pillow under their left arm.

Answer 112

B. The client reports numbness of the fingers of the left hand.

Question 113

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care? A. Administer oxygen at 2 L/min. B. Encourage use of incentive spirometry for 5 minutes every 2 hours. C. Teach the client a breathing exercise with a longer inhalation phase. D. Limit fluid intake to 1,000 mL per day.

Answer 113

A. Administer oxygen at 2 L/min.

Question 114

A nurse is preparing a client for a magnetic resonance angiography (MRA). The client is allergic to iodinated contrast dye. Which of the following actions should the nurse plan to take? A. Administer prednisone before the test. B. Consult with the provider to change to a CT scan. C. Assess the alkaline phosphatase level. D. Obtain the client's allergy history to seafood.

Answer 114

A. Administer prednisone before the test.

Question 115

A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take? A. Encourage family members to press the PCA button for the client. B. Monitor the client's respiratory status every 4 hours. C. Teach the client how to self-medicate using the PCA device. D. Administer an oral opioid for breakthrough pain.

Answer 115

C. Teach the client how to self-medicate using the PCA device.

Question 116

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 hours. The nurse should anticipate a prescription for which of the following intravenous (IV) medications? A. Epinephrine B. Furosemide C. Nitroprusside D. Desmopressin

Answer 116

D. Desmopressin

Question 117

A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect? A. Petechiae on the chest B. Bradycardia C. Intermittent headache D. Photophobia

Answer 117

D. Photophobia

Question 118

The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator? A. Areas around pins are dry. B. Crusts around pins. C. Purulent drainage around pins. D. Absence of pain at the site.

Answer 118

C. Purulent drainage around pins.

Question 119

A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy? A. Constipation B. Decreased tear production C. Mouth ulcers D. Peripheral neuropathy

Answer 119

C. Mouth ulcers

Question 120

A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? A. Anticonvulsant B. Diuretic C. Antithrombotic D. Opioid analgesic

Answer 120

C. Antithrombotic

Question 121

A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take? A. Remove the weights before changing the client's bed linens. B. Instruct the client to use their elbows to reposition. C. Check pressure points every 12 hours. D. Provide the client with a trapeze bar.

Answer 121

D. Provide the client with a trapeze bar.

Question 122

A nurse is reinforcing discharge teaching with a client on how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? A. Change the ostomy pouch daily. B. Empty the ostomy pouch when it is 2/3 full. C. Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma. D. Apply lotion to the peristomal skin when changing the ostomy pouch.

Answer 122

B. Empty the ostomy pouch when it is 2/3 full.

Question 123

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take? A. Aspirate the catheter to check for a brisk blood return. B. Use sterile technique for the procedure. C. Cleanse the insertion site with hydrogen peroxide. D. Flush the TPN port with 20 mL of 0.9% sodium chloride.

Answer 123

B. Use sterile technique for the procedure.

Question 124

The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain: A. Two tablets PO (by mouth) every 15 minutes. B. One tablet SL (sublingual) every 15 minutes, up to 5 times. C. One tablet PO (by mouth) every one hour, up to 5 times. D. One tablet SL (sublingual) every 5 minutes, up to 3 times.

Answer 124

D. One tablet SL (sublingual) every 5 minutes, up to 3 times.

Question 125

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations? A. Severe, throbbing headache B. Hypotension C. Fever D. Cyanosis of the head and neck

Answer 125

A. Severe, throbbing headache

Question 126

A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Frequent exposure to low-volume noise B. Chronic infections of the middle ear C. Perforation of the eardrum D. Born with a high birth weight E. Use of a loop diuretic

Answer 126

B. Chronic infections of the middle ear C. Perforation of the eardrum E. Use of a loop diuretic

Question 127

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse? A. Inject the medication into the abdomen above the level of the iliac crest. B. Use a 1-inch needle to inject the medication. C. Use a 25-gauge needle to inject the medication. D. Massage the injection site after administration of the medication.

Answer 127

C. Use a 25-gauge needle to inject the medication.

Question 128

A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP? A. Papilledema B. Restlessness C. Projectile vomiting D. Decorticate posturing

Answer 128

B. Restlessness

Question 129

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching? A. The client moves the cane 2 feet ahead. B. The client holds the cane with their right hand. C. The client takes a step with their left foot first. D. The client advances the weaker (left) leg forward to the cane.

Answer 129

D. The client advances the weaker (left) leg forward to the cane.

Question 130

A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching? A. "I will draw the regular insulin into the syringe first." B. "I will store prefilled syringes in the refrigerator with the needle pointed upward." C. "I will gently roll the NPH vial between my hands before drawing up the insulin." D. "I will insert the needle at a 90-degree angle."

Answer 130

A. "I will draw the regular insulin into the syringe first."

Question 131

A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow? A. "Do you feel like you have food stuck at the base of your throat?" B. "Do you feel any burning sensations in your throat?" C. "Do you have any feelings of fullness in the neck?" D. "Do you have any problems with pain while swallowing?"

Answer 131

A. "Do you feel like you have food stuck at the base of your throat?"

Question 132

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make? A. "Were you careful to not have carbohydrates after the run?" B. "It is normal to feel this way after a morning run." C. "It becomes easier when exercise is a routine." D. "Did you decrease your insulin intake before you exercised?"

Answer 132

D. "Did you decrease your insulin intake before you exercised?"

Question 133

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. Increased temperature C. Lethargy D. Decreased heart rate

Answer 133

B. Increased temperature

Question 134

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? A. Clear items from the client's surrounding area. B. Loosen the client's restrictive clothing. C. Lower the client to the floor. D. Obtain the client's vital signs.

Answer 134

C. Lower the client to the floor.

Question 135

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station? A. A client who has a headache following a grade 1 concussion. B. A client who has experienced brain death and is awaiting organ procurement. C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash. D. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack.

Answer 135

C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash.

Question 136

A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take? A. Wear sterile gloves when collecting the sample. B. Discard samples that contain urine. C. Collect three samples from a single bowel movement. D. Take the sample from the outer edge of formed stool.

Answer 136

B. Discard samples that contain urine.

Question 137

A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take? A. Instruct the client to expect tingling in their extremities. B. Measure blood glucose every 2 hours. C. Limit the client's fluid intake. D. Instruct the client to lie flat.

Answer 137

D. Instruct the client to lie flat.

Question 138

A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Blood pressure 138/76 mm Hg B. Temperature 36.3°C (97.3°F) C. Heart rate 48/min D. Respiratory rate 10/min

Answer 138

C. Heart rate 48/min

Question 139

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take? A. Perform a Mantoux skin test on the client. B. Assign the client to a negative-pressure airflow room. C. Wear a surgical mask when providing care to the client. D. Recommend that the client's family members receive antiviral therapy.

Answer 139

C. Wear a surgical mask when providing care to the client.

Question 140

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 glycemic control? A. Glycosylated hemoglobin level B. Postprandial blood glucose level C. Fasting blood glucose level D. Oral glucose tolerance test results

Answer 140

A. Glycosylated hemoglobin level

Question 141

A nurse is caring for a client who has acute heart failure and received morphine intravenously 30 minutes ago. Which of the following findings should the nurse identify as an indication that the medication was effective? A. Decreased urinary output B. Emesis of 250 mL C. Decreased anxiety D. Increased respiratory rate to 26/min

Question 142

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hours. Which of the following actions should the nurse take in managing the client's PICC line? A. Change the transparent membrane dressing daily. B. Access the catheter using a non-coring needle. C. Maintain a continuous IV infusion through the PICC line. D. Flush the catheter with a 0.9% sodium chloride solution after each use.

Answer 142

D. Flush the catheter with a 0.9% sodium chloride solution after each use.

Question 143

A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include? A. "Display a monthly calendar in the client's room." B. "Provide plenty of stimulation in the client's room." C. "Keep the client's room dark at night to promote sleep." D. "Provide the client with structured activities to fill their time."

Answer 143

A. "Display a monthly calendar in the client's room."

Question 144

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 increase the amount of fresh fruits and vegetables I consume." B. "I will be sure to wear gloves and wash my hands when I change my cat's litter box." C. "I will need to take my clothes to the dry cleaners to sterilize them." D. "I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash."

Answer 144

B. "I will be sure to wear gloves and wash my hands when I change my cat's litter box."

Question 145

A nurse is planning care for a client who is postoperative following the insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care? A. Check the pulse distal to the graft. B. Keep the left forearm below the level of the heart. C. Collect blood specimens from the graft. D. Splint the left forearm to prevent damage to the graft.

Answer 145

A. Check the pulse distal to the graft.

Question 146

A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage? A. Heart rate 60/min B. Oxygen saturation 95% C. Blood pressure 90/50 mm Hg D. Respiratory rate 14/min

Answer 146

C. Blood pressure 90/50 mm Hg

Question 147

A nurse is caring for a client who has developed hives and urticaria following the administration of IV contrast dye after a cardiac catheterization. Which of the following medications should the nurse plan to administer? A. Desmopressin B. Diphenhydramine C. Spironolactone D. Metoclopramide

Answer 147

B. Diphenhydramine

Question 148

A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room? A. Tongue blade B. NG tube C. Oral airway D. Wrist restraints

Answer 148

C. Oral airway

Question 149

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement? A. Move the client to a double room. B. Use a bed alarm. C. Encourage participation in activities that provide excessive stimulation. D. Use chemical restraints at bedtime.

Answer 149

B. Use a bed alarm.

Question 150

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make? A. "Your provider wouldn't prescribe this medication if it weren't necessary." B. "If you don't take this medication, you will feel worse." C. "Most clients feel better after taking the antibiotic." D. "I will tell your provider that you do not want to take this medication."

Answer 150

A. "Your provider wouldn't prescribe this medication if it weren't necessary."

Question 151

A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and ST-segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer? A. Digoxin B. Sotalol C. Atropine D. Lidocaine

Answer 151

C. Atropine

Question 152

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? A. 150 mL of serosanguineous drainage B. 75 mL of greenish-yellow drainage C. 100 mL of red drainage D. 200 mL of brown drainage

Answer 152

C. 100 mL of red drainage

Question 153

A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? A. Turn the CPM machine off while the client is eating. B. Store the CPM machine on the floor when not in use. C. Check the settings of the CPM machine every 12 hours. D. Increase the range of motion rapidly when the CPM machine is used intermittently.

Answer 153

A. Turn the CPM machine off while the client is eating.

Question 154

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. Instruct the client to avoid eating raw vegetables. B. Initiate a referral for the client to a home health agency. C. Remind the client of the importance of medication adherence. D. Tell the client to avoid places where there are large crowds of people.

Answer 154

B. Initiate a referral for the client to a home health agency.

Question 155

A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? A. Check the client's blood pressure every 8 hours. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Administer opioids orally.

Answer 155

C. Assess urine output hourly.

Question 156

A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? A. Rinse your mouth with hydrogen peroxide. B. Brush your teeth for 60 seconds twice daily. C. Floss your teeth gently following each meal. D. Wear your dentures only during meals.

Answer 156

B. Brush your teeth for 60 seconds twice daily.

Question 157

A nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first? A. Glucose Dextrose Oral (GDO) B. Epinephrine (Adrenaline) C. Dexamethasone (Decadron) D. 0.9% Normal Saline

Answer 157

B. Epinephrine (Adrenaline)

Question 158

A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect? A. Epithelialization at the site B. Severe pain at the site C. Edema at the site D. Blistering at the site

Answer 158

C. Edema at the site

Question 159

A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment? A. Tap the client's facial nerve and note any facial twitching. B. Strike the client's patellar tendon with a percussion hammer and note any increase in response. C. Gently elevate the client's head and note any nuchal rigidity. D. Run a tongue blade on the outside of the client's sole and note any flaring of the toes.

Answer 159

C. Gently elevate the client's head and note any nuchal rigidity.

Question 160

A nurse is caring for a group of clients who are 12 hours postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome? A. Thyroidectomy B. Internal fixation of a fractured hip C. Repair of a torn rotator cuff D. Tympanoplasty

Answer 160

B. Internal fixation of a fractured hip

Question 161

The nurse is caring for several clients on a hospital unit. Which of the following clients is most at risk for hypoglycemia? A. A client with type 1 diabetes mellitus who has taken a high dose of insulin B. A client who has type 2 diabetes and has not taken any medication C. An older adult client taking an antibiotic for an infection D. A client who has metabolic syndrome and is taking a statin drug to lower cholesterol levels

Answer 161

A. A client with type 1 diabetes mellitus who has taken a high dose of insulin

Question 162

A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following pieces of information should the nurse include in the teaching? A. "The spacer should make a whistling sound as you inhale." B. "Hold your breath for 10 seconds once you inhale." C. "Clean the spacer daily with cold water." D. "Wait 30 seconds between puffs."

Answer 162

B. "Hold your breath for 10 seconds once you inhale."

Question 163

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include? A. Place the client's bed at the lowest height. B. Request a prescription for a nightly sedative. C. Assist the client with toileting at least once every 4 hours. D. Turn off all lights in the client's room at night.

Answer 163

A. Place the client's bed at the lowest height.

Question 164

A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up? A. "I do my best to protect my skin from bumps and cuts. It's more fragile now." B. "I guess feeling down is just part of aging." C. "My hair is thinning. I'm going to go to the wig shop soon." D. "I missed my eye appointment, but I rescheduled it."

Answer 164

B. "I guess feeling down is just part of aging."

Question 165

A client who has a terminal illness asks the nurse, "If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?" Which of the following statements should the nurse provide to explain a DNR prescription? A. A DNR prescription means you will only receive pain medication for your treatments. B. A DNR prescription will limit your current treatment regimen. C. A DNR prescription will allow you to continue with your current treatment regimen. D. A DNR prescription will limit your ability to receive invasive procedures.

Answer 165

C. A DNR prescription will allow you to continue with your current treatment regimen.

Question 166

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. 1/2 cup nonfat yogurt C. 1 medium baked potato with skin D. 2 tbsp peanut butter

Answer 166

A. 1 cup white rice

Question 167

A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? A. Give the dosimeter badge to the oncoming nurse at the end of the shift. B. Limit family member visits to 30 min per day. C. Remove soiled linens from the room after each change. D. Apply a second pair of gloves before touching the client's implant if it dislodges.

Answer 167

B. Limit family member visits to 30 min per day.

Question 168

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? A. Kussmaul respirations B. Increased urine output C. Cool, clammy skin D. Acetone breath

Answer 168

C. Cool, clammy skin

Question 169

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take? A. Monitor the client's vital signs once every hour. B. Elevate the head of the client's bed to a 45° angle. C. Restrict the client's fluid intake. D. Instruct the client not to bend the affected leg.

Answer 169

D. Instruct the client not to bend the affected leg.

Question 170

A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take? A. Raise the drainage system to the client's chest level. B. Clamp the tubing to check for air leaks. C. Empty the collection chamber. D. Gently squeeze the tubing to remove excess drainage.

Answer 170

B. Clamp the tubing to check for air leaks.

Question 171

A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown? A. A client who has occasional urinary incontinence B. A client who has inadequate nutrition C. A client who has moderate Alzheimer's disease D. A client who is paraplegic

Answer 171

D. A client who is paraplegic

Question 172

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse expect? A. Pain occurs about 1 hr after eating B. Pain in the right lower quadrant C. Reports of constipation D. Eating food relieves pain

Answer 172

A. Pain occurs about 1 hr after eating

Question 173

A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider? A. "My parent has type 2 diabetes mellitus." B. "I wish my family was more supportive of my decision." C. "I am not very good about taking prescribed medication." D. "I had symptoms of asthma when I was a child."

Answer 173

C. "I am not very good about taking prescribed medication."

Question 174

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations? A. Decreased responsiveness of airways to allergens B. Suppressed bronchiolar inflammatory response C. Inability to exhale retained carbon dioxide D. Acute loss of alveolar elasticity

Answer 174

C. Inability to exhale retained carbon dioxide

Question 175

A nurse is providing teaching about client rights to a client who has a brain tumor. Which of the following client statements indicates an understanding of the teaching? A. “I could refuse the treatment even after it has started." B. "I signed the surgical consent form because there are no other options." C. "If I choose not to accept my provider's plan of treatment, I will not be able to do any other treatment." D. "I am going to have radiation treatment because it has no adverse effects."

Answer 175

A. “I could refuse the treatment even after it has started."

Question 176

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A. "Avoid napping during the day." B. "Avoid using ice packs when joints are inflamed." C. "Take a hot shower to reduce pain in the morning." D. "Decrease the amount of iron in your diet."

Answer 176

C. "Take a hot shower to reduce pain in the morning."

Question 177

A nurse is preparing to administer intramuscular epinephrine to a client who is experiencing anaphylaxis. Which of the following sites should the nurse use? A. Ventrogluteal B. Vastus lateralis C. Dorsogluteal D. Deltoid

Answer 177

B. Vastus lateralis

Question 178

A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching? A. The client advances their right foot to meet their left foot. B. The client maintains two points of support on the floor. C. The client holds the cane in their left hand. D. The client moves the cane forward 50.8 cm (20 in) when ambulating.

Answer 178

B. The client maintains two points of support on the floor.

Question 179

A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include? A. Remain at least 1 foot away from young children during treatment. B. Use cloth handkerchiefs instead of disposable tissues. C. Use absorbent briefs for incontinence as needed. D. Flush the toilet with the lid closed three times after use.

Answer 179

D. Flush the toilet with the lid closed three times after use.

Question 180

A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately? A. Bruising around the incisional site B. Pallor in the affected extremity C. Urine output 150 mL over 4 hr D. Temperature of 37.9° C (100.2° F)

Answer 180

B. Pallor in the affected extremity

Question 181

A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take? A. Determine the client's blood type. B. Institute bleeding precautions. C. Avoid administering IV pain medication. D. Implement airborne precautions.

Answer 181

B. Institute bleeding precautions.

Question 182

A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority? A. Surgical site B. Respiratory Status C. Level of consciousness D. Pain level

Answer 182

B. Respiratory Status

Question 183

A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching? A. "I will use canola oil when making salad dressing." B. "I will increase my intake of canned vegetables." C. "I will limit my portions of meat to 8 ounces." D. "I will drink whole milk with my cereal."

Answer 183

A. "I will use canola oil when making salad dressing."

Question 184

A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make? A. "Twist at the waist when standing from a seated position." B. "Move your stronger leg first when using a walker." C. "Use a raised toilet seat to maintain your hips above your knees." D. "Apply a heating pad to the operative hip to decrease pain."

Answer 184

C. "Use a raised toilet seat to maintain your hips above your knees."

Question 185

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. Generalized abdominal pain B. Increased heart rate C. Cloudy effluent D. Fever

Answer 185

C. Cloudy effluent

Question 186

A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A: Administer an antihypertensive medication intravenously. B: Confirm that the client's bladder is empty. C: Indicate the risk for autonomic dysreflexia in the client's medical record. D: Place the client in an upright sitting position.

Answer 186

D: Place the client in an upright sitting position. B: Confirm that the client's bladder is empty. A: Administer an antihypertensive medication intravenously. C: Indicate the risk for autonomic dysreflexia in the client's medical record.

Question 187

A nurse manager is providing an in-service to a group of newly licensed nurses about the use of personal protective equipment. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?. A. "I should wear a gown to remove linens from a client's bed." B. "Sterile gloves are required when administering an IM injection." C. "I should use both hands to recap a needle." D. "I should wear goggles when irrigating a wound."

Answer 187

D. "I should wear goggles when irrigating a wound."

Question 188

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take? A. Tie knots in the ropes near the pulleys to shorten them. B. Increase the elevation of the affected extremity. C. Remove one of the weights. D. Pull the client up in bed.

Answer 188

D. Pull the client up in bed.

Question 189

Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client. Medical History Diagnostic Results Nurses' Notes Client is lying in bed. Awake, alert, and oriented to time, place, and person. Client is febrile and reports weakness. Receiving TPN via central line in left antecubital. Client is NPO and has had diarrhea x3 in past 4 hr. Crackles auscultated in posterior lobes. A . Obtain client weight twice daily. B . Have 3 nurses verify the TPN solution prescription. C . Request a prescription for insulin. D . Request an antibiotic to be administered. E . Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula. F . Notify provider to increase TPN rate/hr.

Answer 189

A . Obtain client weight twice daily - ANTICIPATE B . Have 3 nurses verify the TPN solution prescription - ANTICIPATE C . Request a prescription for insulin - ANTICIPATE D . Request an antibiotic to be administered - ANTICIPATE E . Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula - NONESSENTIAL F . Notify provider to increase TPN rate/hr - CONTRAINDICATED

Question 190

A nurse in a health clinic is caring for a client. Medical History: HIV The client is at risk for developing ______ due to ______

Answer 190

bleeding platelet count

Question 191

A nurse is caring for a client who is postoperative following a total knee arthroplasty Medical History Type 2 Diabetes Mellitus Hypertension: Controlled by diuretic and ACE-inhibitor therapy Osteoarthritis The client is at highest risk for _________ as evidenced by the ______.

Answer 191

wound infection blood glucose level

Question 192

A nurse is caring for a client who has COPD. Click to highlight the findings below that require immediate follow-up. A. Client is restless B. tachypneic, cough is productive C. mucous is yellow D. Wheezes and crackles E. Oxygen saturation 87% on room air F. Pulse 110/min G. oriented to person, place, and time H. Able to move all extremities

Answer 192

A. Client is restless B. tachypneic, cough is productive C. mucous is yellow D. Wheezes and crackles E. Oxygen saturation 87% on room air F. Pulse 110/min