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3 Months Free Update
3 Months Free Update
3 Months Free Update
A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible. His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?
To facilitate maximum air exchange, the nurse should position the client in:
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
A 27-year-old primigravida at 32 weeks’ gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
The physician orders medication for a client’s unpleasant side effects from the haloperidol. The most appropriate drug at this time is:
With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
A client has been diagnosed with thrombophlebitis. She asks, “What is the most likely cause of thrombophlebitis during my pregnancy?” The nurse explains:
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:
Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications, if ordered, would the nurse question?
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, “Nobody in here seems to really care about the clients. I thought nurses cared about people!” The client is exhibiting the ego defense mechanism:
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
The nurse is in the hallway and one of the visitors faints. The nurse should:
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child’s mother for the home treatment of croup?
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, “I just couldn’t take it anymore.” The nurse’s best response to this disclosure would be:
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1–2 hours if needed. The most likely rationale for this order is:
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
Hematotympanum and otorrhea are associated with which of the following head injuries?
As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:
In cleansing the perineal area around the site of catheter insertion, the nurse would:
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:
Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration?
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
A nurse should carefully monitor a client for the following side effect of MgSO4:
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should:
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to:
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:
An 18-month-old child has been playing in the garage. His mother brings him to a nurse’s home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:
Nursing assessment of early evidence of septic shock in children at risk includes:
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:
Which of the following physician’s orders would the nurse question on a client with chronic arterial insufficiency?
A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as:
A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:
When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, “I haven’t exercised in 6 days. I won’t be eating lunch today.” This statement by her most likely reflects:
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of the following statements?
A newborn girl’s father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4” and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:
In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig’s sign. The nurse expects her to react to discomfort if she:
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
A client is pleased about being pregnant, yet states, “It is really not the best time, but I guess it will be OK.” The nurse’s assessment of this response is:
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to “fatigue,” and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse’s assessment of her behavior would most likely be:
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
A physician’s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, “I can’t stay still at night. I toss and turn and can’t fall asleep.” The nurse suspects that she may be experiencing:
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a “Trendelenburg gait.” This gait is characteristic of:
A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:
A 4 year old has an imaginary playmate, which concerns the mother. The nurse’s best response would be:
The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:
Parents should be taught not to prop the bottle when feeding their infants. In addition to the risk of choking, it puts the infant at risk for:
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis—Alteration in comfort, pain related to:
Goal setting for a client with Meniere’s disease should include which of the following?
When assessing a female child for Turner’s syndrome, the nurse observes for which of the following symptoms?
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most effective response would be:
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
An IDDM client’s condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec’s cirrhosis of the liver. The nurse knows the pruritus is directly related to:
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
A group of nursing students at a local preschool day care center are going to screen each child’s fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to:
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
A burn victim’s immunization history is assessed by the nurse. Which immunization is of priority concern?
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.” The best response by the nurse would be:
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:
A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care:
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as:
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, “This is too much trouble. I would rather just have a Foley.’’ An appropriate response for the RN teaching him would be:
At 38 weeks’ gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client’s fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:
The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be:
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele’s rule, the estimated date of confinement is:
A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?
What is the appropriate nursing action for a child with increased intracranial pressure?
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question?
A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse assesses this behavior as:
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the nurse’s initial response would be:
A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:
A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first
24 hours after surgery and cast application?
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:
A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?
A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client’s glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:
A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
Home-care instructions for the child following a cardiac catheterization should include:
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her
room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:
Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer’s disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:
A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing. Given the client’s symptoms, nursing assessment would focus on:
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
Which of the following ECG changes would be seen as a positive myocardial stress test response?
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
A pregnant woman at 36 weeks’ gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being “on the move,” sleeping 3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is “rule out hepatitis.” Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:
The nurse practitioner determines that a client is approximately 9 weeks’ gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
A client with a C-3–4 fracture has just arrived in the emergency room. The primary nursing intervention is:
A client is 6 weeks pregnant. During her first prenatal visit, she asks, “How much alcohol is safe to drink during pregnancy?” The nurse’s response is:
Pregnant women with diabetes often have problems related to the effectiveness of insulin in controlling their glucose levels during their second half of pregnancy. The nurse teaches the client that this is due to:
Which of the following statements relevant to a suicidal client is correct?
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
A client has renal failure. Today’s lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse’s first action would be to:
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:
A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son’s circumcision?
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, “Nurse, the baby is coming.” As the nurse responds to her call, which one of the following observations should the nurse make first?
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A female client at 30 weeks’ gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
A female client comes for her second prenatal visit. The nurse-midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.” Which notation will the nurse include in her plan of care for the client? “Will need . . .
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client’s self-esteem by:
As soon as a child has been diagnosed as “hearing impaired,” special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?
A female client is concerned that she is in a “high-risk” group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16–20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent’s home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client’s family. The nurse explains necessary precautions, which include:
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a “miscarriage” with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks’ gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele’s rule, the nurse estimates her date of delivery to be:
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse’s knowledge of the anatomy of the respiratory system in pediatric clients?
An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse’s first action should be to:
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
TESTED 13 Sep 2025