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After placing a 36-week-gesation newborn in an isolette and drying the infant with several blankets, what Should the nurse implement next? a. Administer the vitamin K injection. b. Remove the wet blankets and linens from the isolette. c. Place erythromycin opthalmic ointment in both eyes. d. Open the door to assess the infant's vital signs. - correct answer b. Remove the wet blankets and linens from the isolette. A client in the third trimester of pregnancy com- plains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement? - correct answer d. Record the respiratory findings in the clients record as normal A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? a. Ask family to remain nearby, but in another room. b. Encourage family to speak often with the client. c. Teach family how to assist the client to a wheelchair. d. Instruct family to offer client only soft, bland foods - correct answer d. Instruct family to offer client only soft, bland foods A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground material is observed in the drainage from the nasogastric tube (NGT), which Intervention should the nurse implement? a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage. c. Listen for evidence of diminished bowel sounds. d. Irrigate the nasogastric tube with water until clear. - correct answer a. Verify correct placement of the nasogastric tube The nurse Is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the client's clinical recovery? a. Lipase. b. Creatinine. c. Bilirubin. d. Glucose. - correct answer a. Lipase. While assessing a client who had a laparotomy the previous day, the nurse notices that 300 ml of dark red fluids has drained from the nasogastric tube In the last hour. Which action should the nurse take first? a. Determine the clients vital signs b. Monitor urinary output hourly. c. Notify the surgeon immediately. d. Assess the client's level of pain. - correct answer a. Determine the clients vital signs The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times. b. Use nasal or cough tissues followed by hand washing at all times. c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines. d. Avoid large crowded areas during the colder months of the year - correct answer d. Avoid large crowded areas during the colder months of the year
a. Muscle stiffness. b. Abdominal pain. c. Mental stupor. d. Fruity breath. - correct answer d. Fruity breath. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a. Explain that the client may be placed in five positions b. Instruct the client to breathe shallow and fast. c. Obtain arterial blood gases (ABGs) prior to procedure. d. Perform the drainage immediately after meals. - correct answer a. Explain that the client may be placed in five positions A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DR) prescription. Which action should the nurse take? a. Initiate an ethics committee review of the case b. Place a DR bracelet on the client's arm. c. Ensure resuscitation equipment is available. d. Ask the family to review options with the client. - correct answer a. Initiate an ethics committee review of the case In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a. Cornea are jaundiced. b. Oral mucosa is cyanotic c. Face is flushed and diaphoretic. d. Eyelids are matted and crusted. - correct answer b. Oral mucosa is cyanotic
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse lake in response to the finding? a. Ask the client to describe recent alcohol use. b. Keep the client's feet elevated when in bed. c. Assess the client's muscle strength and tone d. Complete thorough neurologic assessment - correct answer d. Complete thorough neurologic assessment Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. Ensure that the drainage bag is attached to the bed frame. b. Ensure continued sterility of the specimen container c. Securely fasten the clamp on the drainage bag. d. Label the container with the client's identifiers. - correct answer b. Ensure continued sterility of the specimen container The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. Hold the walker securely to prevent slipping when the client rises. b. Apply a gait belt to assist the client to rise out of the chair. c. Instruct the client to use the arms of the chair for support. d. Encourage client to use the weaker leg with the walker when rising. - correct answer a. Hold the walker securely to prevent slipping when the client rises. A client with cancer complains of fever, chills, malaise, and headache following administration of a colony- stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu-like symptoms?
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant? a. Chickenpox b. Mumps c. Sore throat d. Influenza - correct answer c. Sore throat Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Review with the client the need to avoid foods that are rich in milk and cream. c. Reinforce this teaching by asking the client to list dairy foods that he might select. d. Suggest that the client also plan to eat frequent small meals to reduce discomfort. - correct answer b. Review with the client the need to avoid foods that are rich in milk and cream. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure. b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. c. Decreased renin-angiotensin response related to an increase in renal blood flow. d. Decreased portacaval pressure with greater collateral circulation. - correct answer a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure. The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation?
a. An incompetent lower esophageal sphincter. b. A weakened diaphragm with high, abdominal pressure c. Intestinal scar tissue buildup from a chronic condition. d. A history of having Helicobacter pylori infection. - correct answer b. A weakened diaphragm with high, abdominal pressure An adult recently diagnosed with glaucoma, tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses. b. Eat a diet high in carotene. c. Avoid frequent eye pressure measurements. d. Maintain prescribed eyedrop regimen - correct answer d. Maintain prescribed eyedrop regimen The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client: a. with pneumonia whose serum potassium level is 6.5 mg/dl. b. with atrial fibrillation, whose saline lock is infiltrated c. who is receiving a heparin infusion and has developed hematuria. d. with hypertension whose blood pressure is 230/118. - correct answer b. with atrial fibrillation, whose saline lock is infiltrated Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has a streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) - correct answer 0.4 mL A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
d. The intake of protein should be decreased due to the progressively failing function of the kidney. - correct answer c. The protein intake should be decreased to prevent nitrogenous waste buildup. A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires Immediate Intervention by the nurse? a. Orientation to person and place only. b. Unequal bilateral hand grip strengths c. Pupillary changes to ipsilateral dilation. d. Left-sided facial drooping and dysphagia. - correct answer b. Unequal bilateral hand grip strengths As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a. Removing gastric secretions and to relieve abdominal distention. b. Reducing hydrochloric acid secretion. c. Restoring and maintaining a positive fluid balance. d. Decreasing the formation and secretion of pancreatic enzymes. - correct answer d. Decreasing the formation and secretion of pancreatic enzymes. A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? a. Advise the client that the treatment is having a beneficial effect. b. Instruct the client to obtain prostate-specific antigen (PSA) testing. c. Inform the client that his chemotherapy dose will probably be increased d. Discuss options for hospice care with the client and family members. - correct answer a. Advise the client that the treatment is having a beneficial effect. The nurse plans to administer a bolus dose of IV Heparin based on the client's weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin should the nurse administer? (Enter numeric value only.) - correct answer 9000
A successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. Reinforce the reality of his financial situation. b. Direct him to drink a glass of red wine at bedtime. c. Teach him to limit sugar and caffeine intake. d. Encourage him to initiate daily rituals. - correct answer c. Teach him to limit sugar and caffeine intake. The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asks about information of the treatment options.. Which Information is most helpful for the nurse to provide? a. Emphasize the addictive nature of popular medications. b. Offer effective time management strategies. c. Explore the combination of medication and behavioral therapies d. Discuss dietary changes such as increasing protein intake. - correct answer b. Offer effective time management strategies. A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 mL over the past 24 hours with a central venous pressure of 15 mmH. The nurse notes respiratory crackles and bounding central pulses. Vital signs: temperature 101.2 °F (38.4° C), heart rate 96 beats/minute, respirations 24 breaths/minute, and blood pressure of 160/90 mmH. Which intervention should the nurse implement first? a. Review last administration of IV pain medication. b. Decrease IV fluids, to keep vein open rate. c. Administer PRN dose of acetaminophen. d. Calculate total intake and output for last 24 hours. - correct answer b. Decrease IV fluids, to keep vein open rate.
a. Pupil response. b. Heart sounds. c. Urinary output. d. Temperature. - correct answer c. Urinary output. An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Decreased abdominal girth. b. Prothrombin time within normal limits. c. Improved level of consciousness. d. Clear, dark amber-colored urine. - correct answer a. Decreased abdominal girth. Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. Smooth nail texture. b. Scattered macula on the face. c. Capillary refill 5 seconds. d. Absence of skin tenting. - correct answer c. Capillary refill 5 seconds. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. Silence allows the client to reflect on what was said. b. The nurse is respecting the client's loss. c. The nurse is stating disapproval of the statement. d. Silence is reflecting the client's sadness. - correct answer a. Silence allows the client to reflect on what was said.
The nurse is assessing the mood of a depressed male client. When asked how he feels, the client looks down and states, "I don't know I just can't think " Which activity should the nurse suggest that this client perform? a. Complete a written self-esteem assessment. b. Review the client handbook about unit therapies c. Set daily goals in the community meeting. d. Read, "The Depression Recovery Book." - correct answer a. Complete a written self-esteem assessment. A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experiencing a generalized abdominal aching. Her blood pressure has decreased and her pulse has Increased over the past two hours. While waiting for the healthcare provider to arrive, which intravenous solution is best for the nurse to initiate? a. Normal Saline (NS) at 20 mL/hour. b. Lactated Ringer's (LR) at 150 mL/hour. c. D5W/0.45 NS at 125 mL/hour. d. Dextrose 10% (D10W) at 83 mL/hour. - correct answer a. Normal Saline (NS) at 20 mL/hour. While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement? a. Investigate the reason for the call bell alarm then complete the admission assessment. b. Tell the unit clerk to ask the client via the intercom what is needed. c.Ask a coworker to respond to the client whose call bell is alarming. d. Complete the postoperative admission assessment then investigate the call bell alarm. - correct answer a. Investigate the reason for the call bell alarm then complete the admission assessment. A client with rheumatold arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
d. When the client's bladder is distended. - correct answer a. Immediately after the client voids. The nurse is reviewing a client's urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding? a. Explain that the urine finding is normal. b. Recommend the use of salt with meals. c. Tell client to report reduced urine output less than 1,000 mL/day. d. Instruct client to increase oral fluids to a minimum of 2,400 mL/day. - correct answer d. Instruct client to increase oral fluids to a minimum of 2,400 mL/day. A client with heart failure reports increased of shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement? a. Auscultate the lungs. b. Review serum potassium. c. Measure urine output. d. Administer albuterol via nebulizer. - correct answer c. Measure urine output. An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding Is the nurse likely to obtain? a. Jugular vein distension. b. Fatigue. c. Hepatomegaly. d. Lower extremity edema. - correct answer b. Fatigue. Which client is the most likely candidate for total parenteral nutrition (TPN)? a. A client diagnosed with type 1 diabetes in diabetic ketoacidosis.
b. An obese client who is on a medically supervised starvation diet. c. An older client who is having a laparoscopic cholecystectomy. d. A client experiencing an acute exacerbation of Crohn's disease. - correct answer d. A client experiencing an acute exacerbation of Crohn's disease. A mother brings her 3-year-old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102° F (38.9°C. He is drooling and becoming increasingly more restless. What action should the nurse take first? a. Put a cold cloth on his head and administer acetaminophen. b. Assist the child to lie down and examine his throat. c. Notify the healthcare provider and obtain a tracheostomy tray. d. Listen to lung sounds and place him in a mist tent. - correct answer c. Notify the healthcare provider and obtain a tracheostomy tray. An adolescent female with an eating disorder is admitted to the in-patient psychlatric unit. Which intervention should the nurse implement? a. Encourage the client to weigh herself daily at bedtime. b. Allow the client to select an arts and crafts activity. c. Recommend exercise and recreation in the morning. d. Put the client in charge of choosing snacks for the unit. - correct answer a. Encourage the client to weigh herself daily at bedtime. An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? (Select all that apply.) a. Recommend installing grab bars by toilets, bathtub, and shower. b. Have the home health nurse assess the home for fall risks. c. Encourage exercise to improve balance and mobility. d. Wear an emergency response pendant at home.
d. A client with multisystem failure secondary to a motor vehicle collision. - correct answer c. A client with chest tubes secondary to a stab wound to the chest. The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition for her child, but is concerned about the cost. How should the nurse respond? a. Advise the mother that these foods will only be needed until the growth spurt of the toddler years is complete. b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients c. Affirm that these prepared foods are the best way to ensure that the toddler gets all the needed nutrients. d. Teach the mother how to develop a budget to allow her to continue to provide the needed prepared toddler foods. - correct answer b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe a PRN dose of an oral over-the- counter laxative for a client who is constipated. What instruction should the nurse provide the unit clerk? a. Be sure to write down what is prescribed and then repeat it back to the healthcare provider. b. Remain with this client and monitor the vital signs while the nurse takes the call. c. Ask the healthcare provider to remain on "hold" until the nurse can confirm the prescription. d. Tell the healthcare provider the nurse will return the phone call as soon as possible. - correct answer d. Tell the healthcare provider the nurse will return the phone call as soon as possible. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first? a. Elevate the client's right hand on one or two pillows. b. Notify the healthcare provider of the finding immediately.
c. Measure the client's blood pressure and apical pulse rate. d. Complete a neurovascular assessment of the right hand. - correct answer a. Elevate the client's right hand on one or two pillows. A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. while planning care, the nurse is most concerned about preventing which complication related to these findings? a. Atelectasis. b. Exit site infection. c. Peritonitis. d. Outflow obstruction. - correct answer c. Peritonitis. A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond? a. "You may have an increased chance of having preeclampsia." b. "You may be at higher risk for having a spontaneous miscarriage." c. "This medication will have no effect on your unborn child." d. "You may experience postpartum hemorrhaging after delivery." - correct answer b. "You may be at higher risk for having a spontaneous miscarriage." The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes should the nurse recommend the client wear when ambulating with her husband's assistance? a. Slip-on rubber shower shoes. b. Tennis shoes with Velcro. c. Rubber soled slippers. d. Leather soled loafers. - correct answer b. Tennis shoes with Velcro.
