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VERIFIED QUESTIONS AND ANSWERS
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. ✓ Platelets 35,000 mm^3 (35 × 109 /L) ✓ Sodium 150 mEq/L (150 mmol/L) ✓ Segmented neutrophils 40% (0.40) ✓ White blood cells, 3000 mm^3 (3.0 × 10^9 /L)
A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
✓ Answers-Ensures that a close relative stays with the client
✓ Makes a referral for a Catholic priest to visit the client ✓ Offers to provide a means for praying the rosary if the client wishes.
Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5) ✓ Latino American Man ✓ Native American man ✓ Hispanic American man ✓ African American woman
The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? ✓ I cannot have any food containing or Prepared with blood."
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the
VERIFIED QUESTIONS AND ANSWERS
client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
VERIFIED QUESTIONS AND ANSWERS
✓ Encourage the client to discuss the use of an herbal substance with the health care provider (HCP).
- The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?
✓ "Magnetic therapy and massage therapy are a focus of CAM."
- The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?
✓ The client was found lying on the floor.
- A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
✓ Transport the victim to the operating room for surgery.
The nurse has just assisted a client back to bed aftera fall. The nurse and health care provider have assessed theclient and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
✓ Answers-Continue with the instructions, verifying client understanding.
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- The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?
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- Which identifies accurate nursing documentation notations? Select all that apply.
✓ The client slept through the night.
✓ Abdominal wound dressing is dry and intact without drainage.
✓ The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
- A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?
✓ Observing care provided to the client without the client's permission
- Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort?
✓ Slander
- An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
VERIFIED QUESTIONS AND ANSWERS
✓ As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
- The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?
✓ Contact the nursing supervisor.
- The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?
✓ Call the nursing supervisor and report the incident.
- The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
✓ A client with asthma who requested a breathing treatment during the previous shift
- The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?
✓ A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
- A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing
VERIFIED QUESTIONS AND ANSWERS
- The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?
✓ A client who requires urine specimen collections
- The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.
✓ Move beds away from windows.
✓ Close window shades and curtains.
✓ Place blankets over clients who are confined to bed.
- The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?
✓ A client requiring abdominal wound irrigations and dressing changes every 3 hours
- The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.
✓ The acuity level of the clients
✓ Client needs and workers' needs and abilities
- The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional
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manifestations would the nurse expect to note in this client if excess fluid volume is present?
✓ An increase in blood pressure and increased respirations
- The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?
✓ Requires nasogastric suction
- The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2. mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
✓ U waves
✓ Inverted T waves
✓ Depressed ST segment
- Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
✓ Obtain an intravenous (IV) infusion pump.
✓ Monitor urine output during administration.
✓ Monitor the IV site for signsof infiltration or phlebitis.
✓ Ensure that the medication is diluted in the appropriate volume of fluid.
VERIFIED QUESTIONS AND ANSWERS
- The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5. mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.
✓ Tall peaked T waves
✓ Widened QRS complexes
- Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
✓ The client who is taking diuretics
- The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
✓ Hyperactive bowel sounds
- The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?
✓ Malnutrition
- The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?
✓ Integumentary output
- The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
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3
✓ A client with an ileostomy
- The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
✓ Weight loss and poor skin turgor
- On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?
✓ The client with kidney disease and a 12-year history of diabetes mellitus
Which client is at risk for the development of a potassium level of 5.5mEq/L (5.5 mmol/L)? ✓ The client who has sustained a traumatic burn
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco 2 of 30 mm Hg (30 mm Hg), and HCO –^ of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? ✓ Respiratory alkalosis, compensated
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? ✓ Metabolic alkalosis
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? ✓ An increased pH and an increased HCO 3 –
VERIFIED QUESTIONS AND ANSWERS
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco 2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? ✓ Potassium level of 3.0 mEq/L (3.0 mmol/L)
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? ✓ Respiratory acidosis from inadequate ventilation
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? ✓ Holding the next dose of warfarin
A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? ✓ "I will be sure to cue in to any indicators that the client may be exaggerating their pain."
A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? ✓ 15 mg/dL (5.25 mmol/L)
The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?
✓ Taking an oral temperature for a client with a cough and nasal congestion
- A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The
VERIFIED QUESTIONS AND ANSWERS
client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?
- A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? ✓ Leaving the rate of the heparin infusion as is
- A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? ✓ 3.2 mEq/L (3.2 mmol/L)
- The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply. ✓ Warfarin ✓ Glimepiride ✓ Amlodipine
- A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? ✓ Preventing and recognizing hyperglycemia
- The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? ✓ 2000 mm^3 (2.0 × 10^9 /L)
- A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the
VERIFIED QUESTIONS AND ANSWERS
The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? ✓ Cream of wheat, blueberries, coffee
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? ✓ Vitamin B 12
A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? ✓ Summer squash
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. ✓ Broth ✓ Coffee ✓ Gelatin
The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? ✓ Smoked sausage
A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? ✓ Custard
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? ✓ Oranges
The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has
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the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? ✓ Legumes
- A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? ✓ Decrease PN rate to 50 mL/hour.
- The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? ✓ Take a deep breath, hold it, and bear down.
- A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? ✓ On the left side, with the head lower than the feet
- Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? ✓ Determine whether the client has an allergy to eggs.
- The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? ✓ Weakness, thirst, and increased urine output
- The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? ✓ Client's temperature
- The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? ✓ Obtain a different bottle of solution.
