NCLEX Nursing Preparing for Exams

1. - Document the client's refusal in the A nurse is caring for a client who refuses a blood transfusion. Which of the following ac- medical record tions should the nurse take? - Notify risk management about the client's refusal - Document the client's refusal in the medical record - Inform the client that the transfusion is mandatory - Suggest that the client explore alternative therapies 2. a nurse is assessing a client who has left-sided Frothy, pink sputum heart failure. which of the following findings should the nurse identify as a manifestation of pulmonary congestion? Frothy, pink sputum weight gain bradypnea jugular vein distention 3. A nurse is caring for a client at a clinic. Adm 1 week ago: Client reports that manifestations of hopelessness and disinterest are lessened, but present. Sleep disturbance continues. Provider increased paroxetine to 30 mg daily. Return to clinic in 1 week. 2 weeks ago: 1 / 71 Serotonin syndrome Adverse effects of paroxetine Client with a history of generalized anxiety disorder and major depressive disorder. Client presents with increased hopelessness, disinterest, and a change in sleep and appetite over several months. Client is currently taking fluoxetine 20 mg daily for the past year. Fluoxetine discontinued and paroxetine 10 mg daily started. Return to clinic in 1 week. Complete the following sentence by using the lists of options. The client is at risk for developing Select... due to Select.... Mania Serotonin syndrome Psychosis Feelings of hopelessness Adverse effects of paroxetine Anxiety 4. a nurse on a medical surgical unit is planning - Complete activities for one client becare for assigned clients. Which of the follow- fore moving to the next client. ing actions should the nurse plan to take to demonstrate effective time management? - Complete activities for one client before moving to the next client. - Document assessment findings and interventions after providing care for a group of clients. - Gather supplies for a client's dressing change 2 / 71 after removing the old dressing. - Delay cleaning personal work area until the end of the shift. 5. A. Measure the arm circumference a nurse is planning care for a client who is scheduled to receive a peripherally inserted above the insertion site daily. central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? A. Measure the arm circumference above the insertion site daily. B. Administer sedation C. Schedule an MRI post procedure to verify placement D. Use gauze to secure an arm board to the involved extremity 6. A nurse is caring for a client in an outpatient clinic. First office visit: Erythrocyte sedimentation rate (ESR) 21mm/hr (up to 20 mm/hr) Hct 36% (37-47) Hgb 12 g/dL (12-16) WBC count 6000/mm3 Uric acid 6.1 (2.7-7.3) 6mo follow up: Erythrocyte sedimentation rate (ESR) 22mm/hr (up to 20 mm/hr) Antinuclear antibodies positive 3 / 71 Rheumatoid arthritis ESR Hct 35% (37-47) Hgb 11 g/dL (12-16) WBC count 4000/mm3 Uric acid 6.3 (2.7-7.3) Complete the following sentence by using the list of options. The client is at risk for developing ____ as evidenced by _____ 7. Supplement feeding with sterile water = CON Dress in only diaper = IND For each nursing action, click to specify if the Cover newborn's eyes with a shield = action is indicated or contraindicated for the IND newborn. Apply lotion to skin every 4 hr = CON Breastfeed every 2-3 hr = IND Supplement feeding with sterile water Dress in only diaper Cover newborn's eyes with a shield Apply lotion to skin every 4 hr Breastfeed every 2-3 hr 8. Also on Pt.1 A nurse is caring for a recently admitted 18-year-old client. Nurses' Notes The nurse is preparing the infant for phototherapy. Anorexia Nervosa - Provide a structured meal environment - Focus on the client's underlying feelings dysphoria of and lack of control 1000: Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client's parents - Behavior 15 min after meals were called. They contacted the primary care - Cardiac function with ECG 4 / 71 provider, who arranged for a direct admission. Weight 37.2 kg (82 Ib) Height 157.5 cm (62 inches) BMI 15 9. A nurse is caring for a client who has cancer D. "Would you like to speak to a spirand is terminally ill. The client reports feeling itual advisor? depressed. Which of the following statements should the nurse make? A. "Do you need a prescription for an antianxiety medication?" B. "Do you need information on hospice care?" C. "Would you like to talk to a counselor about advance directives?" D. "Would you like to speak to a spiritual advisor? 10. For each potential nursing intervention, click Encourage naps during the day when to specify if the intervention is indicated or not client is tired - IND indicated. Encourage a regular sleep-awake schedule - IND Encourage high calorie finger foods NOT Advise client to notify provider if pregnant - NOT Instruct client to avoid foods that have been fermented or aged - NOT 5 / 71 Advise client to rise slowly from sitting position - IND Encourage client to sleep until later in the morning - NOT 11. A nurse is caring for a postpartum client in an - mastitis outpatient setting. - cracked nipple Nurses' Notes Discharge from acute care facility note 2 days postpartum: Client discharged to home with newborn. Fundus firm, midline, and measures two finger breadths below umbilicus. Lochia scant rubra. Episiotomy site well approximated. Mild labial edema present. Voiding without difficulty. Breastfeeding newborn every 2 to 3 hr. Denies any pain with breastfeeding, nipples intact. Reports increased firmness in breasts. Complete the following sentence by using the lists of options. The client is at high risk for developing ???? as evidenced by the client's ??? - endometritis - mastitis - perineal hematoma 6 / 71 - large for gestational age newborn - group b streptococcus - cracked nipple 12. The nurse understands that the patient has - lithium toxicity likely developed ??? and will need to be mon- - seizure activity itored for ??? - lithium toxicity - UTI - metabolic syndrome - neuroleptic malignant syndrome - blood glucose - seizure activity - symptoms of infection - temperature over 39.4C (103F) 13. A nurse is planning to administer vancomycin a. Give the dose over 60 min IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose 14. A nurse is caring for a client in a clinic, Nurses' Notes 0900: A 16-year-old client reports to the clinic with 7 / 71 D. Client experiences nightmares E. Witnessing their family's death, F. Caregiver reporting client acting differently than usual their caregiver. The client's caregiver informs H. Smoking marijuana to clear their the nurse that the client has "not been them- mind. selves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths. Select the 4 findings require immediate follow up A. BP 122/80 mmHg. B. Heart rate 99/min. C. Startles easy during thunderstorm. D. Client experiences nightmares. E. Witnessing their family's death. F. Caregiver reporting client acting differently than usual. G. Attends school regularly. H. Smoking marijuana to clear their mind. 15. For each potential nursing action, click to spec- Report burning in chest to provider ify if the action is indicated or not indicated for IND the client. Reinforce dressing around the tube Report burning in chest to provider as needed if it loosens - IND Reinforce dressing around the tube as needed Maintain water level at 2cm - CONT if it loosens Strip the tubing twice daily to ensure Maintain water level at 2cm patency - CONT Strip the tubing twice daily to ensure patency Clamp chest tube when client ambuClamp chest tube when client ambulates lates - CONT 8 / 71 16. A nurse is caring for a client who has a preC. Document the reaction in the medscription for 1 unit of packed RBCs. Five min- ical record. utes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take? A. Administer epinephrine subcutaneously. B. Place the blood bag in a biohazard bag before discarding. C. Document the reaction in the medical record. D. Infuse 500 ml lactated Ringer's IV. 17. Which of the following statements should the b. Wear flat or low heeled shoes nurse include in the client's teaching? Select all d. wear loose fitting clothing that apply . f. you should avoid fried foods a. Take hot showers to help relieve itching b. Wear flat or low heeled shoes c. you can douche twice weekly d. wear loose fitting clothing e. try using an abdominal support belt f. you should avoid fried foods g. eat two large meals a day 18. A nurse is caring for an adolescent client who d. using an albuterol inhaler has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? 9 / 71 a. Take pancrealipase b. complete oral hygiene c. eat a meal d. using an albuterol inhaler 19. a nurse is caring for a client in the outpatient - difficulty sleeping - frequent headaches mental health clinic - bp 169/91 highlight THE FINDINGS: client states "im feeling much better.* They report less fatigue, even though they have difficulty sleeping, client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation Vital Signs bp 169/91 Heart rate 78/mm respiratory rate 18/min 20. a nurse is assigning tasks to an assistive per- Perform postmortem care sonnel. which of the following tasks should then there's a sign to the AP? - Perform postmortem care - Suction a new tracheostomy - Change a dressing on an implanted central venous access device - Remove an NG tube 21. A nurse is assessing a client who is in active labor. Which of the following findings should 10 / 71 FHR baseline 170/min the nurse report to the provider? Temperature 37.4° C (99.3° F) Early decelerations in the FHR FHR baseline 170/min Contractions lasting 80 seconds 22. A nurse is positioning a client for a cesarean Place a wedge under one of the client's hips. birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? A. Insert a pillow under the client's knees. B. Position the client in reverse Trendelenburg. C. Assist the client into the lithotomy position. D. Place a wedge under one of the client's hips. 23. A nurse is providing teaching to a client who Swelling of the face is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? Swelling of the face Bleeding gums Urinary frequency Faintness upon rising 24. A nurse is giving an intramuscular injection to A. Neonatal Infant Pain Scale (NIPS) a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales 11 / 71 should the nurse use to assess the newborn's pain? A. Neonatal Infant Pain Scale (NIPS) B. FACES pain rating scale C. Premature infant Pain Profile (PIPP) D. visual analog scale (VAS) 25. A nurse manager is preparing to meet with Facilitate discussion until all parties a group of staff nurses who are experiencagree. ing conflict. Which of the following mediation strategies should the nurse manager plan to implement to resolve the conflict? Establish demands from each party that allow for negotiations. Direct anyone who becomes angry to leave the room. Determine who is at fault in the situation. Facilitate discussion until all parties agree. 26. A nurse is reviewing the medical records of A client who is taking warfarin and has an INR of 1.8 four clients. The nurse should identify that which of the following client findings requires follow-up care? A client who is taking bumetanide and has a potassium level of 3.6 mEq/L A client who is scheduled for a colonoscopy 12 / 71 and is taking sodium phosphate A client who is taking warfarin and has an INR of 1.8 A client who received a Mantoux test 48 hr ago and has an induration 27. A nurse is evaluating the laboratory values of A. Increased hemoglobin level a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication? A. Increased hemoglobin level B. Increased platelet count C. Increased neutrophil count D. Increased erythrocyte sedimentation rate 28. A nurse manager on an interprofessional team c. Recommend to the provider a list of is creating a disaster plan. The nurse should clients for early discharge. include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? a. Act as a spokesperson to provide information to the media. b. Determine the need for additional providers. c. Recommend to the provider a list of clients for early discharge. d. Determine which clients should be transported for a higher level of care 29. 13 / 71 A nurse is reviewing home recommendations C. Ensure that all area rugs are rubwith a client who is postoperative following ber-backed. knee surgery. Which of the following recommendations should the nurse make? A. Place a handrail in the entryway of the house. B. Place a towel on the floor outside of the shower. C. Ensure that all area rugs are rubber-backed. D. Wear slippers with cloth soles 30. lower extremity assessment weight assessment blood pressure nausea DTR Vital signs 1000 Temp: 99.3F HR: 90 RR: 20 BP: 148/94 O2: 95% RA Select the 5 findings that require follow-up by the nurse. lower extremity assessment fatal heart tracing weight assessment blood pressure nausea respiratory assessment fundal height DTR 31. 14 / 71 Drag one condition and 1 client finding to fill in -placental abruption each blank in the follow sentence -hypertension The client is at risk for developing ??? due to ??? Condition: oligohydramnios placental abruption choreoammonites placenta previa spontaneous abortion Findings: fundal measurement hypertension vomiting hyperreflexia temperature 32. The client is at highest risk for developing ??? The client is at highest risk for deas evidence by the client's ??? and ???? veloping Preeclampsia as evidence by the client's Urinalysis and Pain manage 33. click to specify which of the following actions monitor blood pressure the nurse should anticipate including in the prepare for amniocentesis 15 / 71 client's plan of care. SATA monitor blood pressure initiate contact precautions prepare for amniocentesis apply internal fetal monitor decrease lighting in the client's room check urinary output encourage bed rest assess DTR 34. encourage bed rest assess DTR The nurse continues to care for the client who - 2L via nasal canula is at 30 weeks of gestation - hydralazine: decreases BP Complete the following sentence by using the lists of options. Based on the client findings, the nurse should first administer ??? and then prepare to administer ??? 35. NGN Vitals: BP: 126/94 HR: 85 RR: 20 Temp: 99.7F Urine Specific Gravity Diagnostic results: Urine Specific Gravity 1.035 Albumin 4/5 Prealbumin 25 POTASSIUM 4.2 16 / 71 a nurse is reviewing the medical record of a client which of the following findings should the nurse report to the provider Urine Specific Gravity Temperature Prealbumin Bowel sounds 36. a nurse in the emergency department is receiv- A client who has left shoulder pain ing report on a group of clients which of the and S-T elevation on a 12-lead ECG following clients should the nurse assess first? A client who has left shoulder pain and S-T elevation on a 12-lead ECG A client who has Clostridium difficile and a temperature of 38.6°C(101.5°A) A client who has orthostatic hypotension and 44 pitting edema in the lower extremities A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 37. A charge nurse on a medical-surgical unit is A client who is 1 day postoperative assisting with the emergency response plan following a vertebroplasty following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A client who is receiving heparin for deep-vein 17 / 71 thrombosis A client who has COPD and a respiratory rate of 44/min A client who has cancer and a sealed implant for radiation therapy A client who is 1 day postoperative following a vertebroplasty 38. a nurse is suctioning the airway of a client who C. Presence of a productive cough is receiving mechanical ventilation via an endotracheal tube. which of the following findings should the nurse identify as an indication that the suctioning has been effective? A. Thinning of mucous secretions B. Decreased peak inspiratory pressure C. Presence of a productive cough D. Flattening of the artificial airway cuff 39. A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect? Head circumference exceeds chest circumference Palpable fontanels Natural loss of deciduous teeth Nontender, protruding abdomen 18 / 71 Nontender, protruding abdomen Head circumference exceeds chest circumference - at 2 years old, chest circum becomes larger than head circum. they are equal at 1-2yr Palpable fontanels - posterior font closes at 2 months, anterior font closes at 18mo Natural loss of deciduous teeth - loss baby teeth at school ager (6yrs old) 40. A nurse is providing teaching to the parents of your child can return to school once a child who has varicella. Which of the follow- the legions have crusted over ing instructions should the nurse include in the varicella = chickenpox teaching? your child can return to school after a negative title result your child can return to school once the fever has subsided your child can return to school once the legions have crusted over your child can return to school 24-hours after beginning antibiotics 41. a nurse is assisting the skin turgor of an older sternum adult client. in which of the following areas should the nurse lift the skin? neck abdomen shoulder sternum 42. a nurse on a mental health unit is teaching I should expect the provider to evala newly licensed nurse about the use of me- uate the client within an hour of rechanical restraints which of the following state- straint application ments by the newly licensed nurse indicates an understanding of the teaching? 19 / 71 I should ask the provider to write a prescription for mechanical restraints as needed. I should visually monitor the client continuously when in mechanical restraints I should assess the client's skin integrity every 8 hours while in mechanical restraints I should expect the provider to evaluate the client within an hour of restraint application 43. a nurse is discussing treatment options with a B. Limit use of nicotine gum to 6 client who is experiencing nicotine withdrawal. months which of the following information should the nurse include in the teaching? A. Substitute tobacco use with an electronic cigarettee B. Limit use of nicotine gum to 6 months C. Use progressively larger nicotine patches D. Use up to 40 nicotine leverages per day 44. a nurse is preparing to administer an IV med- A. Doxorubicin hydrochloride ication to a client and accidentally punctures the IV bag causing the medication to leak on the counter. which of the following medications require the nurse to follow facility procedures in the safe handling of a biohazardous material spill? A. Doxorubicin hydrochloride B. Ampicillin Sodium C. Metronidazole D. Phenytoin 20 / 71 C. "You should administer the medication after breakfast" rational: medication used for adhd 45. A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? A. "You should administer the medication at bedtime." B. "Your child should avoid foods containing tyramine." C. "You should administer the medication after breakfast" D. "Your child should avoid excess sodium intake." 46. A nurse is reporting a client's laboratory tests A. INR to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin? A. INR B. Fibrinogen level C. aPTT D. Platelet count 47. A nurse is providing discharge teaching for "You should remove your child's presthe guardian of a school age child following a sure dressing tomorrow" cardiac catheterization. Which of the following instructions should the nurse include in the teaching? "You should give your child a clear liquid diet for 24 hr." 21 / 71 "Your child should stay out of school for 7 days following the procedure" "You should remove your child's pressure dressing tomorrow" Your child can take a tub bath this evening." 48. A nurse is assessing a child who has bacterial b. Fever pneumonia. Which of the following manifestations should the nurse expect? a. Drooling b. Fever c. Tinnitus d. Rhinorrhea 49. A nurse is planning care for a client who is Measure and compare abdominal returning to the unit following open gastric by- girth daily. pass surgery. Which of the following interventions should the nurse include in the client's plan of care? Measure and compare abdominal girth daily. Ambulate the client 48 hr after the procedure. Provide a soft diet on the first postoperative day. Provide 60 mL (2 oz) of fluid intake every 5 min. 50. A nurse on a telemetry unit is assessing a client B. First-degree AV block who is receiving continuous cardiac monitor22 / 71 ing. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. Atrial fibrillation B. First-degree AV block C. Premature ventricular contraction D. Sinus bradycardia 51. A nurse is caring for a client who is in active A. Maternal hypoglycemia. labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal hypoglycemia. B. Maternal fever. C. Chorioamnionitis. D. Fetal anemia. 52. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Monitor progress of task completion with each AP. B. Review the skill level and qualifications of each AP. C. Evaluate the APs' performance of each task. 23 / 71 B. Review the skill level and qualifications of each AP. D. Communicate appropriate tasks to the APS with specific expectations A. Monitor progress of task completion with each AP. C. Evaluate the APs' performance of each task. D. Communicate appropriate tasks to the APS with specific expectations 53. a nurse is creating a plan of care for a client Inspect the client's mouth every 8 who has cancer and is experiencing immuno- hours suppression. which of the following intervention should the nurse include in the plan of care? Monitor the client's vital sings every 12 hours rotate Healthcare staff caring for the client Inspect the client's mouth every 8 hours Provide fresh fruit with the client's meals 54. A nurse is discussing weight loss with a client A. 7.5% who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages? A. 7.5% B. 8.1% C. 13.3% D. 15% 55. A nurse is receiving change-of-shift report for a A client who has a hip fracture and a group of clients. Which of the following clients new onset of tachypnea should the nurse plan to assess first? A client who has epidural analgesia and weakness in the lower extremities 24 / 71 A client who has a hip fracture and a new onset of tachypnea A client who has sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes mellitus and an HbA1c of 6.8% 56. A nurse is providing teaching to a client who "I will use this test to monitor how has diabetes mellitus about the glycosylated well I control my blood glucose levhemoglobin blood test. Which of the following els." statements by the client indicates an understanding of this test? "I will use the results of this test daily to modify my insulin dosage." "I will need to fast prior to taking this test." "I will need to drink a glucose solution to get an accurate result." "I will use this test to monitor how well I control my blood glucose levels." 57. A nurse is providing teaching to a client who is A. "You might experience altered taste to begin external radiation therapy for cancer. sensations." Which of the following information should the nurse include? A. "You might experience altered taste sensations." B. "Use rubbing alcohol to remove the ink 25 / 71 markings." C. "Wear a binder over the radiation site." D. "Wash your skin thoroughly with a washcloth after each treatment." 58. A nurse is performing a skin assessment on a sclera client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice? sclera palms of the hands shoulders face 59. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Client transferred to step-down unit from ICU for continued care following a myocardial infarction 2 days ago. Oriented to room. Client reports a chronic productive cough due to COPD. States they are short of air. Also states that ambulating to the bathroom has resulted in chest pain rated 3 on a 0 to 10 Pain Scale. client appears anxious and reports a fear of dying 60. Drag words from the choices below to fill in each blank in the following sentence. 26 / 71 Client transferred to step-down unit from ICU for continued care following a myocardial infarction 2 days ago. Oriented to room. Client reports a chronic productive cough due to COPD. States they are short of air. Also states that ambulating to the bathroom has resulted in chest pain rated 3 on a 0 to 10 Pain Scale. client appears anxious and reports a fear of dying The client is at risk for developing ??? and ??? stroke 61. the nurse is developing a plan of care with a physical activity recommendations cardiac rehabilitation team. which of the folblood pressure management lowing topics should the nurse recommend the team plan to address with the client? SATA relaxation techniques potential pacemaker placement physical activity recommendations smoking cessation program nitroglycerin self-administration blood pressure management meal planning ideas relaxation techniques cardioversion therapy smoking cessation program nitroglycerin self-administration meal planning ideas 62. the nurse is providing teaching to the client about self-care. select the 4 statements the nurse should include in the teaching. you should avoid salt in your food prior to eating you should aim to consume fish at least twice a week you should avoid salt in your food prior to eatyou should where a medical alert ing bracelet or necklace you should aim to consume fish at least twice 27 / 71 a week you should where a medical alert bracelet or necklace you should keep your nitroglycerin with you at all times you should keep your nitroglycerin with you at all times you should take ibuprofen If you experience mild pain 63. Pain level: 3/10 to 5/10 Pain level - worsening Anxiety level: Less anxious to anxious and pac- Anxiety level - worsening ing in room Temperature - worsening Heart rate - worsening For each finding click to specify a defining indi- Spo2 - worsening cates an improvement in or a worsening of the Respiratory Rate - worsening client's condition Pain level Anxiety level Temperature Heart rate Spo2 Respiratory Rate 64. a nurse is planning care for a client was sched- Instruct the client to empty her bladuled to have a paracentesis. which of the fol- der prior to the procedure lowing actions should the nurse include in the plan of care? Position the client over an overbed table prior to the procedure. 28 / 71 Administer 1 L dextrose 5% in water IV bolus prior to the procedure. Initiate NPO status 4 hr prior to the procedure. Instruct the client to empty her bladder prior to the procedure 65. A nurse is providing discharge teaching to a "I will need to keep my hand elevated client who is postoperative following surgery above my heart for several days." for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? "| should not use my affected hand for 4 to 6 weeks." "I will need to keep my hand elevated above my heart for several days." "| should expect numbness and tingling in my hand." "I can apply heat for the first 24 hours to minimize the pain in my hand." 66. A nurse is observing a newly licensed nurse D. Uses the TPN IV tubing to adminiswho is administering total parenteral nutrition ter the client's next dose of antibiotics (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? A. Schedules a bag and tubing change for 24 29 / 71 hr after the start of the infusion B. Gradually increases the TPN infusion rate each hr until the prescribed rate is achieved C. Plans for a check of the client's fingerstick glucose level every 6 hr D. Uses the TPN IV tubing to administer the client's next dose of antibiotics 67. A nurse is teaching the parents of a school-age A. child who is newly diagnosed with juvenile id- Have the child take a tub bath each iopathic arthritis. Which of the following inter- morning ventions should the nurse include in the teaching? A. Have the child take a tub bath each morning B. Apply splints to the child's extremities during the day. C. Encourage the child to take naps during the day. D. Keep the child on bedrest as long as pain persists. 68. A nurse is caring for a client who received 50,000 units. Which of the following actions should the nurse take first? A. Complete an incident report. 30 / 71 B. Check the client for indications of bleeding. B. Check the client for indications of bleeding. C. Monitor the client's aPTT levels D. Notify the risk manager. 69. A nurse is caring for client who speaks a dif- a. speak in a normal voice at a natural ferent language than the nurse and is using pace an interpreter. Which of the following actions should the nurse take when working with the interpreter? a. speak in a normal voice at a natural pace b. use gestures when speaking with the client c. pause in the middle of sentences d. direct statements to the interpreter 70. a nurse is providing teaching to a cleint who A. "I will wipe my nose instead of has thrombocytopenia following chemothera- blowing it" py. which of the following statements indicates an understanding of the teaching? A. "I will wipe my nose instead of blowing it" B. "I will remove my shoes when I'm inside my house" C. "I will floss between my teeth every time I brush" D. "I will use an enema to manage my constipation" 71. A charge nurse is teaching new staff members Previous violent behavior about factors that increase a client's risk to become violent. Which of the following risk 31 / 71 factors should the nurse include as the best predictor of future violence? A history of being in prison Male gender Experiencing delusions Previous violent behavior 72. a nurse is providing discharges about car safe- D. I will position my baby at a 45-dety to a parent of a newborn. Which of the fol- gree angle in the car seat. lowing statements by the parent indicates an understanding of the teaching? A. I can turn my baby's car seat around when she weighs 15 pounds. B. I can place my baby in the front seat with the airbag turned off. C. I will place my baby in a forward-facing car seat in my back seat. D. I will position my baby at a 45-degree angle in the car seat. 73. A nurse is preparing to apply a transdermal b. Wear gloves to apply the patch to nicotine patch for a client. Which of the follow- the client's skin ing actions should the nurse take? a. Shave hairy areas of skin prior to application b. Wear gloves to apply the patch to the client's skin c. Apply the patch within 1 hr of removing it from the protective pouch d. Remove the previous patch and place it in a tissue 32 / 71 74. A nurse is making an initial postpartum home D. "I think the baby should be sleepvisit. Which of the following client statements ing through the night by now" should the nurse identify as a manifestation of increased risk for child abuse? A. "I try to respond to the baby quickly so she doesn't cry very long." B. "I have several friends who come by to help out with the baby." C. "I want to meet other parents to see if they are going through the same things." D. "I think the baby should be sleeping through the night by now" 75. A nurse is preparing to administer three med- A. Use a syringe to allow the medicaications to a client who is receiving continuous tions to flow by gravity. enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? A. Use a syringe to allow the medications to flow by gravity. B. Flush the NG tube with 5 mL water. C. Dissolve the medications together. D. Add medication directly to enteral feeding. 76. a nurse is assessing a client who has Negative clonus preeclampsia and is receiving magnesium sulfate via continuous IV infusion for which of the following therapeutics should the nurse monitor for the client? Flushed face Negative clonus 33 / 71 Pulse rate 100/min BP 150/92 mm Hg 77. a nurse is caring for a client who has an NG tube with intermittent suction. which of the following actions should the nurse take? Flush the tube with 0.9% sodium chloride. Flush the tube with 0.9% sodium chloride. Replace the NG tube every 24 hr. Increase the suction pressure as tolerated. Position the Client supine in bed. 78. A nurse is preparing to administer levothy2 tablets roxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? 79. A charge nurse is observing a newly licensed D. Assault. nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred? A. Libel. B. Battery. C. Negligence. D. Assault. 80. 34 / 71 C. Determine if the client has A nurse is caring for a client whose partner died in a fire that destroyed their home. Which thoughts about self-harm. of the following actions should the nurse take first? A. Empower the client to feel that he is in charge of his life. B. Find the client a temporary shelter where he can feel safe. C. Determine if the client has thoughts about self-harm. D. Review the client's available social support system 81. a nurse is caring for a client who has systemic raised facial rash lupus erythematosus. Which of the following client findings should the nurse expect? hemangiomas raised facial rash psoriasis Kaposi's sarcoma lesions 82. A nurse is teaching a prenatal class about "I can visit my nephew who has chickinfection prevention at a community center. enpox 5 days after the sores have Which of the following statements by a client crusted." indicates an understanding of the teaching? "| should take antibiotics when | have a virus." "I can visit my nephew who has chickenpox 5 35 / 71 days after the sores have crusted." "I can clean my cat's litter box during my pregnancy." "I should wash my hands for 10 seconds with hot water after working in the garden." 83. a nurse is caring for a client who is recovering it must be frustrating for you to be from a cerebral vascular accident in a rehabil- here itation facility. The client tells the nurse, "I am sick of being in here and I want to go home." Which of the following responses should the nurse make? it must be frustrating for you to be here you should call your partner to discuss this you are making progress in your treatment plan it would be best to discuss your feelings with your provider 84. Determine if the client's health care A nurse is caring for a client who is in a surrogate is aware of the risks and coma and is scheduled for a surgical procedure. Which of the following actions should the benefits of the procedure. nurse take? Send the unsigned informed consent form to the facility's risk manager. Determine if the client's health care surrogate 36 / 71 is aware of the risks and benefits of the procedure. Ensure that the client's family supports the provider's decision for surgery. Determine if the procedure is medically necessary for the client. 85. A nurse is assessing a client who received hy- D. Naloxone. dromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications? . A. Diazepam B. Acetaminophen. C. Ibuprofen. D. Naloxone. 86. A nurse in a PACU is transferring care of a client "The estimated blood loss was 250 to a nurse on the medical-surgical unit. Which milliliters." of the following statements should the nurse include in the hand-off report? "The estimated blood loss was 250 milliliters." "The client is a member of the board of directors." "There was a total of 10 sponges used during the procedure." "The client was intubated without complications." 87. A nurse is caring for a client who presents to Sputum characteristics the ED...Day 1: Client reports, "I have a cough." Weight 37 / 71 Hx present illness: 38 y/o clients presents to ED Travel History w/ a 4-day hx cough, often productive. Reports Temperature fatigue, night sweats, and a low-grade fever. cough? Reports "blood-tinged sputum." Also reports "I used to weigh 167 lbs. Now I weigh 162." Reports a decreased appetite along w/ the 2.26 kg weight loss over the last week. Client states they have been trying to stay hydrated. Fam hx: Child has asthma. All other members healthy. Social hx: Heavy alcohol use (4-5 drinks/day), denies tobacco/illicit drug use. Recently traveled to visit their fam in South Africa and stayed for 3 wks. Exhibit 2: Temp: 38.1 C (100.5 F). BP 112/88 mm Hg. HR 98/min. RR 24/min. O2 Sat 98% on RA Which of the following findings indicate the need for further eval? SATA Report of cough BP Sputum characteristics Weight Travel History Temperature Heart Rate Ox 88. A nurse is caring for a client who presents to Mantoux test & Chest x-ray the ED...Day 1: Client reports, "I have a cough." Hx present illness: 38 y/o clients presents to ED w/ a 4-day hx cough, often productive. Reports fatigue, night sweats, and a low-grade fever. 38 / 71 Reports "blood-tinged sputum." Also reports "I used to weigh 167 lbs. Now I weigh 162." Reports a decreased appetite along w/ the 2.26 kg weight loss over the last week. Client states they have been trying to stay hydrated. Fam hx: Child has asthma. All other members healthy. Social hx: Heavy alcohol use (4-5 drinks/day), denies tobacco/illicit drug use. Recently traveled to visit their fam in South Africa and stayed for 3 wks. Exhibit 2: Temp: 38.1 C (100.5 F). BP 112/88 mm Hg. HR 98/min. RR 24/min. O2 Sat 98% on RA Drag words form the choices to fill in each blank in the sentence: "To further evaluate the client, the nurse anticipates the client will need _____ and _____. 89. The nurse reviews the client's test results N95 (same client). Negative flow Exhibit 1: Screenings: Mantoux test: results pending (nurse will read the results in 48 hr) Exhibit 2: Diagnostic Results: Chest x-ray: Caseation lesions to bilat upper lungs Exhibit 3: History and physical: see previous card Exhibit 4: VS: see previous card Exhibit 5: Lab Results: Sputum culture: positive for M. tuberculosis 39 / 71 Complete the following sentence by using the list of options: The nurse should wear ____ and place ____. 90. Same as prev. cards. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Prescriptions: Isoniazid Airborne precautions Contact precautions Pyrazinamide Ethambutol Monthly TB skin test for 1 year Rifampin 91. - Yellowing of the eyes (Same client as prev card) The nurse is administering meds to the client - Abdominal pain and is monitoring the potential adverse effects - Increased bruising of the meds. For each body system below, click - Increased bleeding tendency to highlight the findings that indicate a serious - Insomnia (?) adverse reaction. - Darkening of the urine Head, Eyes, Ears, Nose, and Throat: - Yellowing of the eyes - Blurred vision - Dry eyes GI: - Abdominal pain - Hard stool 40 / 71 Anticipated: Isoniazid, Airborne precautions, Pyrazinamide, Ethambutol, Rifampin Contraindicated: Monthly TB skin test for 1 year, Contact precautions, from what i got from ATI - Yellowing of the eyes - blurred vision (ethambutol) - Abdominal pain - Increased bruising - Increased bleeding tendency Hematologic: - Increased bruising - Increased bleeding tendency - Insomnia Genitourinary: - Red/orange tint to urine - Darkening of the urine 92. (same client as prev) The nurse is preparing the client for discharge. Select the 3 client statements that indicate an understanding of the teaching. "I will need to have a repeat Mantoux test in 4 weeks." "I can expect my contact lenses to turn red or orange." "I should notify my provider if I start "I will need to have a repeat Mantoux test in 4 taking new OTC or prescription medweeks." ications." "I will need to have someone observe me when I take my medication." i think its: "I will need to take my medications for a total "I will need to have someone observe of 6 weeks." me when I take my medication." "I can expect my contact lenses to turn red or "I can expect my contact lenses to orange." turn red or orange." "I can continue my current alcohol intake." "I should notify my provider if I start "I am no longer contagious." taking new OTC or prescription med"I should notify my provider if I start taking ications." new OTC or prescription medications." u dont do repear mantoux test in 4 weeks. sputum cultures is 4 weeks 93. A nurse is providing teaching to a client who "I should use a soft-bristle toothis undergoing radiation therapy and has stom- brush to clean my teeth after meals." atitis. Which of the following responses by the client indicates an understanding of the teach41 / 71 ing? "I should use a soft bristle toothbrush to clean my teeth after meals." "I should limit my intake of diary products to prevent nausea." "I should gargle with an alcohol-based mouthwash to kill germs." "I should moisten my lips with lemon-glycerin swabs." 94. A nurse manager is updating protocols for the Document the client's condition every use of belt restraints. Which of the following 15 min guidelines should the nurse manager include? Remove the client's restraint every 4 hr. Attach the restraint to the bed's side rails Request a PRN restraint prescription for clients who are aggressive. Document the client's condition every 15 min. 95. A charge nurse is teaching a newly licensed "Information Technology will install a nurse about the facility's computerized docu- firewall to secure client information." mentation system. Which of the following information should the nurse include? "You will be asked to change your password once per year." "Documentation of sensitive material is performed by the charge nurse." "You will be given access to the medical records of every client in the facility." 42 / 71 "Information Technology will install a firewall to secure client information." 96. A nurse in contributing to the plan of care for provide the client with large-handled a client who has multiple sclerosis. The nurse eat eating utensils should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition? Establish alternatives to verbal conversation. Provide the client with large-handled eating utensils. Use the numbers on a clock to describe the position of food on the client's plate. Touch the client's arm before beginning to speak. 97. Administer enalapril 2.5 mg PO twice A nurse is admitting a client who has acute heart failure. which of the following prescrip- daily tions from the provider should the nurse anticDoc said: Infuse 0.9% sodium chloipate? ride 500 mL IV bolus over 1 hr Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr Ambulate the client every 4 hr while awake Provide the client with a 4 g sodium diet. Administer enalapril 2.5 mg PO twice daily 98. A community health nurse is working with a Ensuring that a client who is homegroup of clients. The nurse practices the ethical less receives preventive medical care. principle of distributive justice by performing which of the following tasks? 43 / 71 Keeping a promise to visit with a client who is housebound after the delivery of care. Ensuring that a client who is homeless receives preventive medical care. Being honest with the parents of a child about the need to report suspected abuse. Accepting the decision of an older adult client to live alone in her home. 99. A nurse is caring for a client who asks for Your desire to be an organ donor information regarding organ donation. Which must be documented in writing. of the following responses should the nurse make? I cannot be a witness for your consent to donate. Your desire to be an organ donor must be documented inwriting. Your name cannot be removed once you are listed on the organ donor list. You must be at least 21 years of age to become an organ donor. 100. A nurse is assessing a client who has histrion- Self-centered behavior ic personality disorder. Which of the following manifestations should the nurse expect? Emotional lability Unexpressive affect Splitting behavior Self-centered behavior 44 / 71 101. A nurse is planning care for a toddler who has Initiate droplet precautions. epiglottitis. Which of the following interventions should the nurse include? Offer a high-calorie, high-protein diet. Administer pancreatic enzyme with meals Initiate droplet precautions Carefully suction the child's oropharynx to remove secretions. 102. A nurse is planning care for a preschool-age Monitor the child's cardiac status. child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? Monitor the child's cardiac status. Give the scheduled doses of acetaminophen every 6 hr. Provide stimulation with children of the same age in the play room. Administer antibiotics via intermittent IV bolus for 24 hr. 103. A nurse is teaching a client who plans to be- Choose foods high in vitamin B12 gin following vegan dietary guidelines. Which of the following information should the nurse include? Limit intake of foods high in vitamin C Choose foods high in vitamin B12 Limit intake of nuts and legumes Choose high-fat cheese as a meat substitute 45 / 71 Speech-language pathologist 104. A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult? Dietitian Speech-language pathologist Occupational therapist Physical therapist 105. A nurse is providing discharge teaching to a Avoid hot tubs while wearing the client who has cancer and a prescription for a patch. fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching? Apply the patch to your forearm Remove the patch for 8 hrs everyday to reduce the risk of tolerance Avoid high-fiber foods while taking this medication Avoid hot tubs while wearing the patch 106. A charge nurse is concerned about a recent in- Identify possible precipitating factors crease in facility-acquired catheter infections. related to the infections. Which of the following actions should the nurse take first? Meet with providers to discuss measures to decrease the infections. Identify possible precipitating factors related to the infections. 46 / 71 Schedule nursing staff training for infection control procedures Revise the current policy for catheter care. 107. A charge nurse is concerned about a recent in- B crease in facility-acquired catheter infections. Which of the following actions should the nurse take first? A) Meet with providers to discuss measures to decrease the infections. B) identify possible precipitating factors related to the infections. C) Schedule nursing staff training for infection control procedures. D) Revise the current policy for catheter care 108. A nurse is providing teaching to an older adult A. client who has a seizure disorder and a new "Plan to take this medication with prescription for phenytoin. Which of the fol- food." lowing instructions should the nurse include? A. "Plan to take this medication with food." B. "Plan to take this medication with antacids." C. "Limit foods that contain vitamin D while taking this medication." D. "Limit foods that contain folic acid while taking this medication." A 109. 47 / 71 A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process A) offer to take pictures of the newborn for the client B) discourage the client from allowing friends to see the newborn. C) assure she client that she can have additional children. D) avoid talking to the client about the newborn 110. A nurse is providing discharge teaching to a B new parent about breastfeeding her infant. Which of the following statements should the nurse make? A) Limit the time your infant feeds to 10 minutes on eoch breast. B) Offer your infant the breast when he shows signs of hunger C) Begin each feeding using the same breast. D) Supplement breastfeeding with water every 12 hours. 111. A nurse is caring for a client who has vision A, C, E loss. Which of the following actions should the nurse take? (Select all that apply.) A) Allow extra time for the client to perform tasks. 48 / 71 B) Approach the client from the side. C) Ensure there is high-wattage lighting in the client's room. D) Touch the client gently to announce presence. E) Keep objects in the client's room in the same place 112. A nurse is teaching a client about bladder re- D training for incontinence. Which of the following instructions should the nurse include in the teaching?\ A) "Limit oral fluid intake to 1000 mL per day B) Wear a pair of disposable briefs at bedtime C) Drink 8 oz of citrus juice per day D) Practice pelvic floor exercises regularly 113. A nurse is caring for a client who has end-stage B kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? A) Osteoarthritis B) Hypertension C) Primary Glaucoma D) Amputation 114. A nurse is caring for a client who is in labor and notes that the umbilical cord is pro49 / 71 D lapsed. Which of the following actions should the nurse take? A) Evaluate uterine tone. B) Loosely wrap the cord with petroleum gauze. C) Apply fundal pressure. D) Place the client in Trendelenburg position. 115. A nurse is caring for a child who reports mi- B graine headaches for the past 4 months. Which of the following actions should the nurse take first? A) Request a change in medication from the provider B) Review the child's electronic pain diary C) Set up an appointment with the school nurse D) Refer the family to a chronic pain support group 116. A nurse is caring for a client who has a new di- B agnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider? A) The client is observed mumbling quietly while alone in the day room. B) The client is observed displaying a shuffling gait while walking in the hall 50 / 71 C) The client states, "I feel light headed when I stand up quickly" D) The client states, "Being in the sun seems to really hurt my eyes. " 117. A nurse is admitting a client who is hesitant A. "Advance directives can be signed to create advance directives due to concerns without legal representation." about affording legal representation. which of the following statements should the nurse make? A. "Advance directives can be signed without legal representation." B. "Advance directives can be a verbal agreement between you and your provider until legal review can be obtained C. We can initiate medical care until you get legal assistance in preparing your advance directives D. "A social worker will assist you to find affordable legal representation." 118. highlight the findings that require immediate Temperature 38.2* C (100.8% F) follow up Heart rate 104/min Uterus firm at 1 cm above the umbiliVital Signs: cus and tender to palpation Postpartum day 3, 0815: Moderate amount of dark brown, Temperature 38.2* C (100.8% F) foul-smelling lochia noted. Heart rate 104/min WBC count 33,000/mm* (5,000 to Respiratory rate 18/min 10,000/2 ) BP 108/70 mm Hg Sao, 97% on room air 51 / 71 Nurses' Notes: Postpartum day 3, 0815: • Client reports feeling unwell. : (uent sues tres e im, nedt) and warm with moderate nipple discomfort while breastfeeding. Uterus firm at 1 cm above the umbilicus and tender to palpation. Fundus bogsy but firmed with massage. Moderate amount of dark brown, foul-smelling lochia noted. Surgical incision well approximated with slight edema present, no redness or drainage noted. No bowel movement since birth, hypoactive bowel sounds Diagnostic Results: Postpartum day 3, 0900: Hemoglobin 11.1 mg/d (* 11 g/dL) WBC count 33,000/mm* (5,000 to 10,000/2 ) 119. Specify if the finding increases the client's risk for Uterine Atony or Infection Finding: Prenatal anemia High parity Prolonged rupture of membranes Cesarean birth Polyhydramnios Vital Signs Postpartum Day 3, 0815: 52 / 71 Uterine atony Prenatal anemia High parity Prolonged rupture of membranes polyhydramnios infection prenatal anemia cesarean birth polyhydramnios Temperature 38.2° C (100.8° F) Heart rate 104/min Respiratory rate 18/min BP 108/70 mm Hg SaO, 97% on room air From ATI: Uterine atony High parity Prolonged rupture of membranes cesarean birth polyhydramnios infection prenatal anemia Prolonged rupture of membranes cesarean birth 120. The client is most likely experiencing _____ as The client is most likely experiencing evidenced by the client's _________ mastitis as evidenced by the client's breast and nipple changes 121. The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply. A. Monitor the height and tone fundus. B. contact precautions. C. inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr. D. Request a prescription for terbutaline from the provider. E. Encourage the client to maintain a 53 / 71 A. Monitor the height and tone fundus. B. contact precautions. F. obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab. G. instruct the client to wash her hands before and after changing her perineal pad. semi-Fowler's position to enhance uterine drainage. F. obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab. G. instruct the client to wash her hands before and after changing her perineal pad. Diagnostic Results Postpartum Day 3, 0900: Hemoglobin 11.1 mg/dL (greater than 11 g/du) m) WBC count 33,000/mm* (5,000 to 10,000/2 122. Select the 5 findings that indicate the client's condition has improved. A. Fundal height B. Temperature C. WBC count D. Hgb E. Heart rate F. Lochia Diagnostic Results Postpartum Day 3, 0900: Hemoglobin 11.1 mg/dL (greater than 11 g/dL) WBC count 33,000/mm* (5,000 to 10,000/mm*) Postpartum Day 5, 0600: Hemoglobin 10 mg/dL (greater than 11 g/dL) WBC count 10,000/mm* (5,000 to 10,000/mm?) 54 / 71 A. Fundal height B. Temperature C. WBC count D. Hgb F. Lochia 123. A nurse is building a therapeutic relationship D. Establish the responsibilities of the with a newly admitted client. Which of the fol- nurse and client. lowing actions should the nurse plan to take during the orientation phase of the relationship? A. Assist the client in expressing alternative behaviors. B. Determine previous coping skills used by the client. C. Facilitate the client's problem-solving skills. D. Establish the responsibilities of the nurse and client. 124. A nurse is assessing the fontanels of an B. The anterior fontanel is open 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? A. The posterior fontanel is open. B. The anterior fontanel is open C. Both fontanels are the same size. D. Both fontanels show molding. 125. A nurse is admitting a client who is 1 week C. Request a female interpreter postpartum and reports excessive vaginal through the facility. bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data? A. Have the client's child translate. B. Ask a nursing student who speaks the same language as the client to translate. 55 / 71 C. Request a female interpreter through the facility. D. Allow the client's partner to translate. 126. A nurse is planning teaching for a client D. Avoid using nail polish remover and their family about home oxygen therapy. around the client. Which of the following information should the nurse plan to Include in the teaching? A. Use synthetic fabrics for the client's bedding. B. Clean the equipment with an alcohol-based cleaning product. C. Apply petroleum jelly to soothe the mucous membranes. D. Avoid using nail polish remover around the client. 127. A nurse is caring for a client who is experienc- D. Having interdisciplinary team ing expressive aphasia and right hemiparesis meetings for the client on a regular following a stroke. Which of the following ac- basis tions by the nurse best promotes communication among staff caring for the client? A. Noting changes in the treatment plan in the client's medical record B. Recording the client's progress in the nurses notes C. Posting swallowing precautions at the head of the client's bed D. Having interdisciplinary team meetings for the client on a regular basis A. Swallowing ability 128. 56 / 71 A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? A. Swallowing ability B. Prescribed medications C. Changes in appetite D. Daily fluid intake 129. Bowtie Nurses' Notes Day 1 0400: Client brought in by emergency medical services (EMS) after being found roaming around the college and yelling. Client ran from EMS shouting, "No, you are not going to kill me." and only agreed to seek assistance when another student agreed to accompany the client to the emergency department. Acquaintance reports hearing rumors that the client had odd behaviors like mumbling and talking when no one else was there and always seemed suspicious of everyone. Client appears disheveled and states, "I feel hot." Informed client that they were in the emergency department. Assisted client in changing into a hospital gown. Client was cooperative and appears less anxious. 0415: 57 / 71 Actions to take: Ask What kind of drugs have You been taking? Reduce external stimuli. Potential condition brief psychotic disorder Parameters to monitor Ability to care for self suicide risk Other doc answers: Complication most likely experiencing: - Brief psychotics disorder Action to take: - Reduce external stimuli - Engage with client several times each day to establish trust Client tearfully agreed to be admitted to the mental health unit. Action to take: - Teach client to use self talk - Ask: "What kind of drug have you been taking?" - Reduce external stimuli - Ask: "Have you been sick rece Parameters to monitor - Suicide risk - Ability to care for self 130. A nurse is caring for a client who is experienc- C. Lorazepam ing status epilepticus. Which of the following medications should the nurse expect to administer? A. Lamotrigine B. Carbamazepine C. Lorazepam D. Clonazepam 131. A nurse in a long-term care facility is admitting D. Assist the client to the toilet frea client who has dementia. Which of the follow- quently. ing actions should the nurse take to reduce the risk for client injury? A. Place the bedside table at the foot of the bed. B. Raise the side rails up when the client is in bed. C. Keep the television on during the night. D. Assist the client to the toilet frequently. 132. A nurse is assessing a client who has obses- B. Goal-oriented sive-compulsive personality disorder. Which of 58 / 71 the following findings should the nurse expect? A. Lack of empathy B. Goal-oriented C. Provocative behavior D. Lability 133. A nurse is caring for a client who is experienc- C. Low Fowler's ing increased intracranial pressure following a head injury. In which of the following positions should the nurse place the client? A. Left lateral B. Sims C. Low Fowler's D. Supine. 134. A nurse in the emergency department is as- A. Apply 100% humidified oxygen. sessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first? A. Apply 100% humidified oxygen. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Obtain a baseline ECG. 135. A nurse is reviewing laboratory data from a C. Increased creatinine client who has chronic kidney disease. Which of the following findings should the nurse expect? 59 / 71 A. Increased bicarbonate B. Increased calcium C. Increased creatinine D. Increased hemoglobin 136. A nurse is caring for a 1-day old newborn D. Ensure that the newborn wears a who has jaundice and is receiving photother- diaper apy. which of the following actions should the nurse take? A. Apply lotion to the newborn every 4 he B. Keep the infant's head covered with a cap C. Give the infant 30 ml. (1 or) of glucose water every 2 hr D. Ensure that the newborn wears a diaper 137. A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should take? A. Initiate seizure precautions: A. Initiate seizure precautions: B. Administer oral acetaminophen C. Submerge the adolescent's feet in ice water D. Cover the adolescent with a thermal blanket. 138. A nurse is providing discharge teaching for a B. I will wear loose clothing over my client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching? 60 / 71 A. 1 can hold my cell phone on the same side of my body as the ICD.* B. I will wear loose clothing over my ICD C. I will avoid using my microwave oven at home because of the iCD." D. "I will soak in the tub rather than showering." 139. A nurse is teaching a client who has a new pre- B. Cheese scription for an MAOI. Which of the following foods is contraindicated with this medication? A. Grapefruit B. Cheese C. eggs D. Potatoes B. I can store condoms drawer of my 140. A nurse is teaching a client about condom use. Which of the following client statements nightstand." should the nurse identity as an understanding of the teaching? A. I can re-use the condom one time after initial use. B. I can store condoms drawer of my nightstand." C. *I can use petroleum jelly as a lubricant with the condom." D. I can use natural skin condoms to prevent sexually transmitted infections." 141. A nurse is providing teaching about nonphar- B. Take a hot shower every day. macological pain management to a cilent who 61 / 71 has osteoarthritis. Which of the following instructions should the nurse include in the teaching? A. Place a large pillow under the knees when sleeping. B. Take a hot shower every day. C. Limit dietary intake of phosphorus. D. Place an ice pack directly on the skin of the affected joints. C. I understand the voices are fright142. a nurse observes a client on the psychiatric unit muttering and standing near a window. ening you but I do not hear any voices the client states "the voices are telling me to jump" which of the following is an appropriate response by the nurse? A. Do you recognize the voices belonging to anyone you know? B. You shouldnt be afraid when you think the voices are telling you to hurt yourself C. I understand the voices are frightening you but I do not hear any voices D. that can't be true. the only voices in this room are yours and mine 143. A nurse is caring for a client who is at 33 weeks D. Contractions of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A.Vomiting B. Hypertension 62 / 71 C. Epigastric pain D. Contractions 144. A nurse is providing teaching to the parents of C. *This test should be performed afa newborn about newborn genetic screening. ter your baby is 24 hours old which of the following statements should the nurse Include In the teaching? A. "A nurse will draw blood from your baby's inner elbow. B. "This test will be repeated when your baby is 2 months old." C. *This test should be performed after your baby is 24 hours old D. "Your baby will be given 2 ounces of water to drink prior to the test." 145. A nurse is providing discharge teaching to a D. Eat 1 g/kg of protein per day. client who has chronic kidney disease and is receiving hemodialysis. Which of the following Instructions should the nurse include in the teaching? A. Drink at least 3 L of fluid daily. B. Take magnesium hydroxide for indigestion. C. Consume foods high in potassium. D. Eat 1 g/kg of protein per day. 146. A nurse is developing a plan of care for a new- D. Minimize noise in the newborn's born whose mother tested positive for heroin environment. during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include 63 / 71 in the plan? A. Administer naloxone to the newborn. B. Swaddle the newborn with his legs extended. C. Maintain eye contact with the newborn during feedings. D. Minimize noise in the newborn's environment. B. Perform the procedure prior to 147. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which meals. of the following actions should the nurse take? A. Administer a bronchodilator after the procedure. B. Perform the procedure prior to meals. C. Hold hand flat to perform percussions on the child. D. Perform the procedure twice each day. 148. A school nurse is teaching a parent about ab- A. This type of seizure can be mistaken sence seizures. Which of the following infor- for daydreaming." mation should the nurse include? A. This type of seizure can be mistaken for daydreaming." B. This type of seizure has a gradual onset.C. "This type of seizure lasts 30 to 60 seconds.* D. The child usually has an aura prior to onset 149. A nurse is planning a community health pro- A. Provide daily exercise classes to gram about Parkinson's disease. Which of the improve ambulation for clients who following interventions should the nurse in- have Parkinson's disease 64 / 71 clude as a tertiary prevention strategy? A. Provide daily exercise classes to improve ambulation for clients who have Parkinson's disease B. Provide screenings for community members to identify early manifestations of Parkinson's disease. C. Educate clients about common techniques used to diagnose Parkinson's disease. D. Educate clients who are at risk for Parkinson's disease about maintaining a low-cholesterol diet. A. Administer feedings at a slower 150. A nurse is caring for a client who has diarrhes and is recelving intermittent enteral feed- rate. ings. Which of the following actions should the nurse take? A. Administer feedings at a slower rate. B. Provide chilled formula. C. Discard the open can of formula after 36 hr. D. Flush the tube with 10 mL of water after feedings. 151. A nurse is preparing to administer PRN pain D. Ketorolac medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer? A. Omeprazole B. Acetaminophen 65 / 71 C. Metociopramide D. Ketorolac 152. A nurse is assessing the peripheral catheter B. PhlebitisInsertion site of a client who is receiving an infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse should document the finding as which of the following complications? A. Circulatory overload B. PhlebitisC. Infiltration D. Extravasation 153. A nurse is caring for a client receiving mechan- A. Deliver breaths manually with a reical ventilation via an endotracheal (ET) tube. suscitation bagThe high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take? A. Deliver breaths manually with a resuscitation bagB. Decrease the ventilator flow rate. C. Assess for disconnected tubing D. Reevaluate the client for an ET cuff leak. 154. A nurse is verifying a record of informed con- A. Confirm the client's signature is ausent for a client who is scheduled for surgery. thentic. Which of the following actions should the nurse take? A. Confirm the client's signature is authentic. 66 / 71 B. Provide information on the informed consent form about the benefits of the surgery. C. Inform the client about the condition that requires treatment. D. Explain the procedure to the client before verifying informed consent. 155. A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching? A. "Take your temperature immediately after waking up and before getting out of bed. A. "Take your temperature immediately after waking up and before getting out of bed. B. "Take your temperature within 30 minutes after your first morning void." C. Take your temperature 1 hour after getting out of bed. D. Take your temperature every night before going to bed." 156. A nurse is providing teaching to a client who A. "Use a cane when walking to mainhas a new diagnosis of multiple sclerosis. tain your balance." Which of the following statements should the nurse make? A. "Use a cane when walking to maintain your balance." B. "Place a scatter rug in your bathroom to prevent failing" C. Engage in a rigorous exercise program to maintain muscle tone." 67 / 71 D. Plan to take a hot bath once a week to reduce stress. 157. A nurse is caring for client who has heart A. Weight gain failure. Which of the following manifestations should the nurse expect? A. Weight gain B. Thready pulse C. Tachycardia D. Decreased thirst 158. A nurse is preparing to perform a sterile dress- D. Place the cap from the solution ing change. Which of the following actions sterile side up on a clean surface. should the nurse take when setting up the sterile field? A. Open the outermost flap of the sterile kit toward the body. B. Set up the sterile field 5 cm (2 in) below waist level, C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile f D. Place the cap from the solution sterile side up on a clean surface. 159. A nurse is caring for an adult client who has flush the blood administration tubing chronic anemia and is scheduled to receive a with 0.9% sodium chloride prior to transfusion of 1 unit of packed RBCs. which of the transfusion the following actions should the nurse take? A. administer the blood via 21 gauge IV needle B. check the clients vital signs from the previous shift prior to the initiation of the transfusion 68 / 71 C. flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion D. set the IV infusion pump to administer blood over 6 hr 160. Bowtie client has previous back injury and had back surgery 3 years ago. client takes oxycodone for pain Action: anticipate to administer chlordiazepoxide obtain a prescription for naloxone potential condition opioid intoxication parameters to monitor pupillary response respiratory rate 161. select 4 findings on day 2 that require immediate follow up client restless and agitated. respirations rapid. Brett sounds with crackles heard at bases. client reports substernal chest pain. dressing to right femur with small serosanguinous drainage. movement and sensation of and of right foot intact, skin warm with no change in pigmentation. bilateral pedal pulses 2+ Respiratory rate 69 / 71 Respiratory rate breath sounds heart rate pulse ox pedal pulses breath sounds heart rate pulse ox movement of right foot 162. After notifying the po provider, the nurse should first _________ and then ______________ 2L nc and nitro 58 year old client reporting chest pain is admitted to the emergency department. client states chest pain begain this morning after breakfast and chest pain radiates to left arm. client rates chest pain as 4 on a scale of 10. client has medical history of hypertension, type 2 diabetes mellitus and hyperlipidemia. social history: denies alcohol use, has smoked a pack of cigarettes per day for 35 years current medications: lisonopril 20 mg po daily glucophage 500 mg po bid simvastatin 40 mg po daily administer oxygen at 2L/min via nasal 163. A nurse is caring for a client. Admission Assessment cannula - administer sublingual ni1200: troglycerin 58-year-old client reporting chest pain is admitted to the emergency department. Client states chest pain began this morning after breakfast and chest pain radiates to left arm. Client rates chest pain as 4 on a scale of 0 to 70 / 71 10. Client has medical history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. Social history: denies alcohol use, has smoked a pack of cigarettes per day for 35 years Current medications: Lisinopril Complete the following sentence by using the list of options. After notifying the provider, the nurse should first ??? and then ???? A. Prepare client for cardiac catheterization B. request a prescription for an increase in statin medication C. administer oxygen at 2L/ min via nasal canula A. check a STAT cardiac troponin B. request a prescription for a beta-blocker. C. administer sublingual nitroglycerin 71 / 71